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新型冠狀病毒疫情系列之十二 — 歐洲和英國

2020/4/5 — 8:04

歐洲疫控中心在3月25日發放了第7份疫情報告。直至25日,歐洲及英國共有20萬個個案,11,810人死亡。

在主要來自德國的報告病例中約3成確診者需要入院,4%需要進入深切治療室和呼吸機。入院者中有15%為嚴重病例,12%死亡(嚴重病例的死亡率為77%)。 (註1)

背景

廣告

歐洲和英國的病例已佔全球的63%,由於呼吸機的需要增加,意大利北部的深切治療室超出了負荷。

每十萬人口在14天內累積個案個數是量度新增個案的方法。假設在穩定的測試條件和沒有新的移民因素下,英國和歐洲地區可能在3月尾至4月中的估計個案為每10萬人有100個個案,達到武漢水平。(註2)

廣告

疫情

在3月24日,5萬個病例向歐洲監控中心報告,來自13個個案的1萬4千個病例(97%來自德國)的病情資料中發現,47%發燒;25%咳嗽;16%無力;5%疼痛,其表現與中國的病例有明顯的分別。(註3)

潛伏期一般為5至6天,最新研究表示,它可以潛伏至14天。病毒播放期(不等同於可傳染性)可以在病發前一至二天出現,一般的為8天,重症的可達2周。老年患者的播菌能力特強,病發後5天的排泄可能開始帶菌,一般可以至4至5周,在37天後仍帶菌者也有發現(不一同可以傳染),嚴重病例的播菌能力可以比一般病例高60倍。(註4)

無症狀患者(或病發前傳播)

大部份的無症狀患者在後期都出現某些病狀,有模型估算,在社會傳染中,約48%至62%在未發現症狀前傳播。(註5)

兒童

在研究中的5萬個案例中,十歲以下的佔1%;10-19歲的佔4%。(註6)

孕婦和嬰兒

相比於沙士和中東呼吸綜合症,新型冠狀病毒對孕婦的影響較低,只有2宗個案需要入深切治療室和插喉,沒有死亡個案。雖然一般地採用剖腹產子,宮內傳播似乎不太可能,沒有陰道傳染的證據,母乳沒有發現病毒。(註7)

免疫力

根據沙士和中東呼吸綜合症的數據,有理由相信免疫力可以至三年,同一季度的再感染機會應該極小。(註8)

環境傳播

病毒在實驗中可以在空氣存活3小時,但這不等於在社會環境中相同。例如,在中國的醫院環境中,病毒主要發現手術手套上(15.4%),極小發現在護目鏡上(1.7%)。(顯示空氣傳播雖然,但佔比例很少)(註9)

治療

在各種藥物治療中,尚未能在統計上證明有效,但一般地不建議系統地使用抗生素。有報導指其他非抗生素類的消炎藥可能對病情有害,這並沒有證據支持。(註10)

住院設施

以10萬人口平均計,若有18名患者需要入院,將有12個歐洲國家的深切治療室飽和。

若有10名患者需要入院,所有歐洲國家的高度隔離病房(防氣溶膠傳播)將面臨飽和。(註11)

風險評估

風險評估根據10萬人口在14天內累積個案作比較,在3月25 日為36.1個個案,以此預測,歐洲和英國的所有國家都可能在數天至數周內達至武漢水平。(註12)(柳葉刀期刊另有文章以各國的疫情發展走勢比較,認為歐洲各國將發展與武漢看齊。))

疫情的風險被定為中度,對老人族群定為嚴重。

社區爆發風險

社區爆發風險被評為中度,但若紓緩措施不足則評為十分高風險,因為在這樣的情況下,病毒可播播十分快,過早解禁被認為不當。(註13)

公眾健康

  • 首要建議為勤洗手;
  • 打噴嚏必須用紙巾和立即洗手;
  • 健康人士不建議使用外科口罩,不當使用口罩可帶來反效果。

建議中度患者留在家中自行隔離,有需要尋求醫療服務的建議先致電醫院及待安排。(註14)

口罩

外科口罩的優先使用者應該是醫護人員和確診及懷疑病例。口罩可以連續使用4小時和多次使用。

以蒸氣、雙氧水氣體、紫外線、伽瑪射線等方法消毒和重複使用口罩的方法正在研究,但尚未有統一的可行方法。(註15)

1比99

沒有證據證明漂白水有效,但仍然建議日常使用1比99或日常購買的濃度為5%的以1比50稀釋使用和經常抹拭家居物品。為了減低漂白水有可能損壞物料,這可以再來70%濃度酒精進行第二次清潔。(註16)

測試套

不建議使用抗體測試(滴血)作臨床測試方法。當物料供應緊張時,無症狀懷疑病例的測試並非必要,但在高危群(老年)中可以考慮。(註17)

病情追踪

追踪呼吸症患者或流感症狀患者的資料,有助於了解疫情擴散情況,一些國家已不建議上述患者找醫生,在這些情況下,電話支援尤為重要。

 

備註

註1 https://www.ecdc.europa.eu/en/publications-data/rapid-risk-assessment-coronavirus-disease-2019-covid-19-pandemic

Among all cases:  Hospitalisation occurred in 30% (13 122 of 43 438) of cases reported from 17 countries (median countryspecific estimate, interquartile range (IQR): 24%, 11-41%)  Severe illness (requiring ICU and/or respiratory support) accounted for 2 179 of 49 282 (4%) cases from 16 countries (median, IQR: 3%, 2-8%). Among hospitalised cases:  Severe illness was reported in 15% (1 894 of 12 961) of hospitalised cases from 15 countries (median, IQR: 16%, 10-24%).  Death occurred in 1 457 of 12 551 (12%) hospitalised cases from eight countries (median, IQR: 10%, 614%

註2

Assuming stable testing policies and no effect of mitigation measures, the EU/EEA and the United Kingdom is predicted to reach 100 COVID-19 cases per 100 000 population (the Hubei scenario) between the end of March and mid-April (Figures A and B, Annex 2).

註3

Among these cases, the most commonly reported clinical symptom was fever (47%), dry or productive cough (25%), sore throat (16%), general weakness (6%) and pain (5%). The frequency of these symptoms differs notably from those reported from China

註4

Incubation period: Current estimates suggest a median incubation period from five to six days for COVID-19, with a range from one to up to 14 days. A recent modelling study confirmed that it remains prudent to consider the incubation period of at least 14 days [13,14].  Viral shedding: Over the course of the infection, the virus has been identified in respiratory tract specimens 1–2 days before the onset of symptoms, and it can persist up to 8 days in moderate cases and up to 2 weeks in severe cases.

註5

Pre-symptomatic transmission has also been inferred through modelling, and the proportion of pre-symptomatic transmission was estimated between 48% and 62%

註6

Children made up a very small proportion of the 50 068 cases reported to TESSy as of 24 March (with known age (<10 years (1%), 10–19 years (4%)).

3 Hospital capacity was evaluated as a function of increasing prevalence of hospitalised COVID-19 cases per 100 000 population and for three levels of hospitalised COVID-19 patients requiring ICU care (5%, 18% and 30% severity scenarios).

註7

No pregnancy losses and only one stillbirth have been reported to date [47]. Intrauterine transmission appears to be unlikely [46,48,49]. Elective Caesarean section deliveries have been commonly reported as a precautionary method to avoid perinatal transmission [46,50,51]. A confirmed COVID-19 neonatal case has been recently reported, however the mode of transmission remains unclear [52]. A neonate born to a confirmed maternal case had negative laboratory results for COVID-19 and died due to multi-organ failure [53].The virus has not been found in breastmilk

註8

Evidence from other coronavirus infections (SARS and MERS) indicates that immunity may last for up to three years and re-infection with the same strain of seasonal circulating coronavirus is highly unlikely in the same or following season.

註9

Virus was detected most commonly on gloves (15.4% of samples) but rarely on eye protection devices (1.7%) [72]. This evidence indicates that fomites may play a role in transmission of SARS-CoV-2 but the relative importance of this route of transmission compared to direct exposure to respiratory droplets is still unclear.

註10

A randomised, controlled, open-label trial of lopinavir/ritonavir in 199 COVID-19 patients in China failed to show any favourable effect on the clinical course or the mortality compared to standard treatment [72]. Hydroxychloroquine has been shown in vitro to alter the uptake of the virus in cells, and a small case series and trial have reported its use in patients during this outbreak in China and Europe. It remains one of the possible therapies that needs to be evaluated through an adequately sized RCT [73,74]. Systemic use of steroids is not recommended because they might increase the viral replication and shedding of the virus along with other steroidrelated side effects [76

Reports that non-steroidal anti-inflammatory drugs worsen COVID-19 through increased expression of angiotensinconverting enzyme 2 (ACE2), whose receptor is used by SARS-CoV-2 to enter the target cells, are not supported by evidence [77].

註11

Based on these estimates, four EU/EEA countries are at a high risk of seeing their ICU capability saturated at a prevalence of 10 hospitalised COVID-19 cases per 100 000 population (approximately twice the mainland China prevalence scenario at the peak of the epidemic). At a prevalence of 18 hospitalised cases per 100 000 (the Lombardy scenario as of 5 March), 12 countries are at a high risk of ICU capability becoming saturated.

註12

The overall 14-day cumulative incidence rate for the EU/EEA and the UK has increased from 3.3 cases per 100 000 population on 11 March to 36.1 cases per 100 000 population on 25 March 2020. There is a growing number of cases in many countries without epidemiological links to explain the source of transmission. Based on the predicted development of the 14-day cumulative notification rate, similar levels to those seen in Hubei providence are expected to be seen in all EU/EEA countries and the UK in a few days to a few weeks.

註13

The risk of occurrence of widespread national community transmission of COVID-19 in the EU/EEA and the UK in the coming weeks is moderate if effective mitigation measures are in place, and very high if insufficient mitigation measures are in place.

註14

There is no evidence on the usefulness of face masks worn by persons who are not ill to prevent infection from COVID19, therefore this is not advisable [80

註15

Research groups and healthcare facilities are currently looking into possible methods to decontaminate and sterilise masks (and other equipment) for re-use. Steam, hydrogen peroxide vapour, ultraviolet germicidal irradiation and gamma irradiation are being explored, but none of these approaches have been standardised.

註16

In the event of shortages of hospital disinfectants, decontamination may be performed using 0.1% sodium hypochlorite (dilution 1:50 if household bleach at an initial concentration of 5% is used) after cleaning with a neutral detergent, although no data are available for the effectiveness of this approach against COVID-19 [121]. Surfaces that may become damaged by sodium hypochlorite may be cleaned with a neutral detergent, followed by a 70% concentration of ethanol. 

註17

At the moment, no POCT has been recommended for diagnostic use by WHO. Self-testing devices are yet to be fully validated.

While symptomatic contacts should always be tested, the testing of asymptomatic contacts of a COVID-19 case can be deferred but should be considered for those with high-risk exposure.

註18

Countries recommending that patients with ARI/ILI should visit general practitioners, should employ sentinel syndromic and virological surveillance as the main methods to assess intensity and spread of COVID-19

In countries recommending that patients with ARI/ILI should not visit general practitioners (GPs), sentinel clinicbased surveillance systems might not be suitable to monitor COVID-19 intensity and spread in the community. In these circumstances, sentinel general practices consulted by patients by telephone could report at least the number and proportion of telephone consultations due to ARI/ILI

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