冬季三重疫情：我們如何應對這個不尋常的季節？
資料來源：Véronique Duqueroy / 2022 年 12 月 29 日 / Medscape/財團法人台灣紅絲帶基金會編譯
Benjamin Davido, MD, PhD（傳染病專家，Raymond-Poincaré 醫院，法國 Garches）表示，該醫院再次發現自己處於前所未有且令人擔憂的境地：三重流行病。 它正在經歷一個特別早的流感季節、呼吸道融合病毒 (RSV) 病例的激增以及 SARS-CoV-2 的死灰復燃。 如何解釋這種流行病，應考慮哪些解決方案（例如戴口罩、保持社交距離以及開展新的疫苗接種和預防運動）？ Medscape Medical News 向 Davido 提出了這些問題。
Medscape：目前幾個國家的疫情形勢堪憂。 在您看來，這是可以預見的嗎？
Davido：事實上，確實存在流感、RSV 感染和 COVID-19 的三重流行。 有些數字令人不寒而慄，而且似乎沒有哪個國家能夠逃脫：美國報告了超過 20% 的流感陽性病例，而全世界尤其是歐洲的流感疫苗接種率基本上不足。 這種情況早有預料，因為今年夏天澳大利亞爆發了一場非常大的流感。 除此之外，還有歐洲疾病預防控制中心關於細支氣管炎和 SARS-CoV-2 循環恢復的警報，結果導致住院人數增加（目前法國的重症監護病房增加了 18%）。 這還不算中國正在發生的事情。 我們已經在全球範圍內忍受了 BQ1.1 變體，而人口幾乎不再免疫，因為很少有人接受了 Omicron 靶向二價追加劑（在法國大約 10%）。
因此，這種情況尤其令人擔憂。 我們正在目睹各種呼吸道感染大量湧現的季節，這在後 COVID 時代是前所未有的。 每天，我都被要求住院治療肺部感染，包括細菌感染。 在過去的 3 個月裡，我們已經看到一些老年患者來到該部門。 今天，我的病人的平均年齡在 50 到 60 歲之間，有些人偶爾只有 30 多歲，就像一名沒有合併症的病人上週因肺炎（嚴重流感）來到這裡，不得不接受重症加護室 . 我再次看到重症加護病房的住院病人，其中包括一名從未接種過 COVID 疫苗的 60 歲婦女。 邏輯上ICU正在尋找下游床位……我們再次需要記住當 Omicron 流行時，住院患者的死亡風險為 7%，而 Delta 浪潮期間為 12%。
Medscape：為什麼這次流行的速度如此之快？
Davido：在 COVID-19 大流行之前，因流感住院的時間從 12 月底到 1 月初開始，1 月下旬達到高峰。 今天，每 2 個患者中就有 1 個患了流感。 我對它的發展速度感到驚訝。 我們有一段時間處於灰色地帶，因為我們沒有在初級醫療保健機構中檢測流感，因此很難評估 COVID 時代這波前所未有的醫院流感浪潮的到來。 但我們現在處於流行病危機管理狀態——我們本週開會列出老年病學可用的床位，以備不時之需。
至於 COVID，當前的變體 (BQ1.1) 比前一個變體 (BA.5) 更具傳染性，浪潮來襲非常快（1 週內病例增加 37%）。 這也許是唯一的好消息。 它應該很快過去，但必然會導致重症患者固有的醫院超負荷。 再一次，因為在日常生活中如果只有 10% 到 20% 的目標人群受到 BA.5 的保護，我們會發現自己處於一個非常尷尬的境地。
關於RSV，我認為我們低估了情況。 我們在醫院動員了細支氣管炎的醫務人員和輔助醫務人員來應對兒科流行病，而剛剛在成人中增加了雙重流行病。 我們的一個錯誤是，在過去的 2 年裡，我們過於關注 COVID，以至於我們無法想像溢出來自其他地方。
Medscape：目前可以設想哪些解決方案來限制這些前所未有的冬季情況下的醫院壓力？
Davido：海浪撞擊的速度越快，它們淹沒醫院的速度就越快，這是肯定的。 但幾乎令人驚訝的是，雖然現在可以使用治療方法（如尼馬曲韋和利托那韋）和疫苗，但還沒有任何措施到位。 我們已經從一個極端走向了另一個極端，聽聽有關 COVID 或口罩的信息，即從一個幾乎講衛生的社會——無論對錯——甚至在沒有科學依據的情況下限制在戶外戴口罩，到我們不再想戴口罩的普遍憤怒。 當我們取消所有這些緩解措施時，我們為這些過去的病毒（即流感和 RSV）火上澆油。 我們處在一個與去年完全不同的地方，我甚至不是在談論 2020 年，當時只發現了大約 30 例嚴重的流感病例……今天，無論是疫苗還是緩解措施或兩者兼而有之，沒有更多的規則，沒有更多的指南針！ 但是，我認為冬天氣象一到，也就是12月1日，我們就得開始在人多的地方重新戴上口罩，提前做好高危人群的疫苗接種工作。
到了這個冬天，不校准我們的流行病監測工具，這似乎是完全瘋狂的，這是否意味著篩查測試、疫苗加強運動、使用保護措施，如掩蔽和社會疏遠等。如果我們繼續這樣下去，下一個 海浪真的要淹沒醫院。
Medscape：您認為人們是否充分了解疫苗接種或緩解措施？
Davido：我認為沒有得到很好的解釋。 關於疫苗接種，我們必須停止考慮劑量，而是考慮新一代疫苗。 我聽說很多人不知道 60 歲以下的人可以接種疫苗。有些人想獲得追加劑，但被認為不允許這樣做！我們堅持為老年人接種疫苗的想法；這是一個非常糟糕的信息，因為你可能已經 50 歲了，並且已經患過心肌梗塞，因此處於危險之中。此外，去年流感疫苗和新冠疫苗同時出台，而今天，每個人都在盡力「管理」疫苗。 如果沒有指導方針，沒有加速和概述的路徑，人們就會迷失方向。 像「所有人都可以接種新的 Omicron 疫苗」這樣的信息比談論第四劑疫苗更有分量。
在以前的世界裡，我們只控制了一種疾病——流感——而且沒有任何緩解措施。一切順利。今天，我們或許應該更加努力。細支氣管炎疫情發生的時候，應該說得很清楚，把緩解措施放回去。然而，衛生部一直對此事保持沉默。我們不知何故被能源和政治新聞所吞沒。我們不再與這些病毒「交戰」（就像我們應該與細菌作戰一樣，因為正如刺胳針最近的一項研究提醒我們的那樣，細菌感染仍然是全球第二大死因）。
寓意是我們不能在一夜之間放棄對抗和預防傳染病的運動；這不合理。我們必須記住並解釋基本的衛生習慣。例如，今天廣受讚譽的「能源節制」鼓勵關閉所有窗戶以節省取暖……但是，如果空間不再通風，我們勢必會增加污染的可能性。目前情況如何？在我們的醫生辦公室裡越來越多地看到病人不戴口罩。
Medscape：我們如何展望對抗這些流行病的未來？
Davido：我們每年都必須重新發起強有力的運動來對抗傳染病，就像它們所做的那樣，例如對抗乳腺癌或結腸癌。 而且，與腫瘤學一樣，我們必須繼續改進和簡化診斷工具並優化治療。明年，我們預計將通過 RSV 疫苗看到對抗細支氣管炎的新武器。一個例子是，有一些工具可以同時篩查流感、COVID 和 RSV。 我們必須對其進行解釋並將其落實到位，並提供所有這些新工具，包括提供給初級保健醫生。
在初級保健和醫院傳染病之間的合作方面也有實際工作要做。我們將需要優化渠道，例如，呼籲和擴大與患者接觸的藥師和專業人員的能力領域。更一般地說，我們需要以更廣泛的方式去組織並想像醫療照護，例如，一個為歐洲整體健康的「歐洲指揮者」。
Medscape：恢復未接種疫苗的照護人員以拯救醫院部門，就像他們在意大利所做的那樣？
Davido：我認為這是一場虛假的辯論，因為並沒有被問到的真正根本問題是，這會解決醫院的問題嗎？ 答案是不。我們說的是大約 4,000 人，其中有很多行政人員、護理人員等。幾乎沒有醫生。 所以，當我們談論這些「照顧者」時，我們必須非常小心。
不過，我理解打疫苗並不能防止感染、醫院裡大家都戴口罩的說法的微妙之處，結果疫苗就變成了可有可無，因為它對病人沒有保護作用。除了這條捷徑，如果我們讓這些工人復職，我認為應該與他們達成默契：如果出現前所未有的浪潮，包括新變異株在內，並且鑑於新的 mRNA 疫苗的可用性大大降低了被感染的可能性，這些人將不得不服從科學和疫苗接種。
話不多說，但這次給看護者打疫苗，在很大程度上使得在浪潮發生時，一方面可以避免曠工，也可以「揭穿」那些自稱是照護者卻不靠科學數據的人。因為我不認為你可以在患有 COVID 或流感的患者的床邊告訴他，「你不接種疫苗並最終接受重症加護照顧是對的」。醫療保健中的倫理是必不可少的。
但我們必須非常清楚：說醫院的倒閉是因為不遵守疫苗接種的工作人員被開除，這是完全錯誤的。 他們的複職當然是可能的，但它不會解決短期或長期的問題。
本文翻譯自 Medscape 法文版。
Triple Winter Epidemic: How Do We Deal With This Extraordinary Season?
Véronique Duqueroy / December 29, 2022/ Medscape
Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.
According to Benjamin Davido, MD, PhD (infectious disease specialist, Raymond-Poincaré Hospital, Garches, France), the hospital once again finds itself in an unprecedented and worrisome situation: a triple epidemic. It is experiencing a particularly early flu season, an explosion of cases of respiratory syncytial virus (RSV), and a resurgence of SARS-CoV-2. How can this epidemic situation be explained, and what solutions (such as masking, social distancing, and new vaccination and prevention campaigns) should be considered? Medscape Medical News raised these questions with Davido.
Medscape: There is currently a worrisome epidemic situation in several countries. Was it foreseeable, in your opinion?
Davido: Factually, there is indeed a triple epidemic of flu, RSV infections, and COVID-19. Some numbers are chilling, and it seems no country can escape them: more than 20% of positive flu cases are being reported in the United States, with largely insufficient flu vaccination coverage around the world, and especially in Europe. This scenario had been predicted, because there was a very large wave of flu in Australia this summer. Added to this is the European Center for Disease Prevention and Control alert on bronchiolitis and the resumption of circulation of SARS-CoV-2, with a consequent increase in hospitalizations (+18% in intensive care units in France currently). And that’s not counting what is happening in China. We’ve endured the BQ1.1 variant worldwide, whereas the population is hardly immune anymore, since few people have received the Omicron-targeted bivalent booster (about 10% in France).
This situation is, therefore, particularly worrisome. We are witnessing a season with a significant number of respiratory infections of all kinds, and this is unprecedented in the post-COVID era. Every day, I am called on for hospitalizations for pulmonary infections, including bacterial ones. Over the past 3 months, we’ve seen a few elderly patients come into the department. Today, the average age of my patients is between 50 and 60 years, and some are occasionally in their thirties, like a patient who, with no comorbidities, arrived last week for pneumonia (severe flu) and had to go through the intensive care unit. I am once again seeing admissions to the ICU, including a 60-year-old woman who had never been vaccinated against COVID. The ICU is logically seeking downstream beds…. We once again need to remember that with Omicron, the risk of death in hospitalized patients is 7%, compared with 12% during the Delta wave.
Medscape: Why is the speed of this epidemic so exceptional?
Davido: Before the COVID-19 pandemic, hospitalizations for flu began between the end of December and the beginning of January, with a peak in late January. Today, 1 in 2 patients I am called to see have the flu. I’m amazed at how quickly it is evolving. We were in a gray area for a while, since we weren’t testing for the flu in primary healthcare settings, so it was difficult to assess the arrival of this unprecedented wave of hospital flu in the COVID era. But we are now in an epidemic crisis management situation — we are meeting this week to list the beds available in geriatrics, in anticipation.
As for COVID, with the current variant (BQ1.1), which is even more contagious than the previous one (BA.5), the wave hits very quickly (+37% of cases in 1 week). This is perhaps the only good news. It should pass quickly, but the corollary, of course, will be the hospital overload inherent in severe forms. And once again, if only 10% to 20% of the target population is protected against BA.5, we’ll find ourselves in a frankly very embarrassing situation, given the total lack of protective measures, such as masking and social distancing, in day-to-day life.
Regarding RSV, I think we underestimated the situation. We mobilized medical and paramedical staff on bronchiolitis at the hospital to counter a pediatric epidemic, while a double epidemic had just been added in adults. One of our mistakes was that for the past 2 years, we focused so closely on COVID that we couldn’t imagine the overflow coming from somewhere else.
Medscape: What solutions can currently be envisioned to limit hospital strain in these unprecedented winter circumstances?
Davido: The faster the waves crash, the faster they’ll inundate the hospital, that’s for sure. But what’s almost astonishing is that, while treatments (such as nirmatrelvir and ritonavir) and vaccines are now available, nothing has been put in place. We’ve gone from one extreme to the other, namely, from an almost hygienist society — rightly or wrongly — with restrictions going as far as wearing a mask outdoors with no scientific basis for it, to a general exasperation where we no longer want to hear about either COVID or masks. As we lifted all these mitigation measures, we stoked the fire for these viruses of yesteryear (that is, flu and RSV). We are in a completely different place than we were last year, and I’m not even talking about 2020, when there were only about 30 serious cases of flu identified…. Today, whether it’s the vaccine or the mitigation measures or both, there are no more rules, no more compass! However, I think that as soon as the meteorological winter arrives, that is to say, December 1, we have to start putting the masks back on in crowded places and anticipate the vaccination of people at risk.
It seems completely crazy to get to this winter period without calibrating our epidemic surveillance tools, whether that means screening tests, vaccine booster campaigns, the use of protective measures, such as masking and social distancing, etc. If we continue like this, the next waves are really going to bury the hospital.
Medscape: Do you think people are sufficiently informed about vaccination or mitigation measures?
Davido: I don’t think it’s being explained well. Regarding vaccination, we have to stop thinking in terms of the number of doses and rather think in terms of new-generation vaccines. I’ve heard many accounts of people who don’t know that people under 60 can be vaccinated. Some would like to get the boosters but think they aren’t allowed to! We clung to the idea of a vaccination that targeted the elderly; it’s a very bad message, because you can be 50 years old and have had a myocardial infarction and therefore be at risk. In addition, last year, the vaccination campaigns against the flu and against COVID came out at the same time, whereas today, everyone “manages” as best they can to get vaccinated. If there are no guidelines, no accelerated and outlined path, people are lost. A message like, “Vaccination with the new Omicron vaccine is open to everyone,” would have more weight than talking about a fourth vaccine dose.
In the world before, we managed only one disease ― it was the flu ― and there were no mitigation measures. It all ran well. Today, we should probably be making more of an effort. When the bronchiolitis epidemic happened, it should have been said very clearly to put the mitigation measures back in place. However, the Ministry of Health has been completely silent on this subject. We were somehow engulfed by energy and political news. We are no longer “at war” against these viruses (just as we should be against bacteria, since, as a recent Lancet study reminds us, bacterial infections remain the second leading cause of death worldwide).
The moral is that we cannot, overnight, abandon campaigns to fight and prevent infectious diseases; it’s not rational. We have to remember and explain basic hygiene. For example, the “energy sobriety” so acclaimed today encourages closing all the windows to save on heating…. However, if there is no more ventilation of the spaces, we are bound to increase the likelihood of contamination. And how does that play out currently in doctor’s offices, where we increasingly see patients not wearing masks?
Medscape: How do we envision the future of the fight against these epidemics?
Davido: We have to relaunch strong campaigns to fight against infectious diseases every year, like they do, for example, with breast or colon cancer. And, as in oncology, we must continue to improve and simplify diagnostic tools and optimize treatments. Next year, we expect to see a new arsenal in the fight against bronchiolitis, through RSV vaccines. One example is that there are tools to screen for the flu, COVID, and RSV all at once. We’ll have to explain it and put it in place and make all these new tools available, including to the primary care doctor.
There is also real work to be done on the collaboration between primary care and hospital infectious diseases. We will need to optimize the channels, eg, to call on and expand the field of competence of pharmacists and professionals in contact with patients. And more generally, we need to organize care in a broader way and imagine, for example, a “European conductor” for European health.
Medscape: Reinstate unvaccinated caregivers to bail out hospital departments, like they did in Italy?
Davido: I think it’s a phony debate, because the real underlying question that is not being asked is, will this solve the hospital’s problem? The answer is no. We’re talking about around 4000 people, and among them, there are a lot of administrative staff, paramedics, etc. There are hardly any doctors. So, we have to be very careful when we talk about these “caregivers.”
Nevertheless, I understand the subtlety of saying that vaccination does not prevent contamination and that everyone wears a mask in the hospital, so as a result, the vaccine becomes optional because it has no protective effect on patients. Beyond this shortcut, if we reinstate these workers, I believe that a tacit agreement should be put in place with them: in the event of a wave of unprecedented magnitude and given the availability of new mRNA vaccines which significantly reduce the likelihood of becoming infected, including with new variants, these people will have to submit to the science and vaccination.
We don’t say it enough, but this vaccination of caregivers has largely made it possible, when the waves occur, on the one hand to avoid absenteeism, but also to “unmask” those who claim to be caregivers but do not rely on scientific data. Because I don’t think you can be at the bedside of a patient who is suffering from COVID or the flu and tell him, “You were right not to get vaccinated and to end up in intensive care.” There are ethics in medical care that are essential.
But we must be extremely clear: to say that the hospital is collapsing because staff were ousted who did not comply with vaccination is completely false. Their reinstatement is certainly possible, but it will not solve the problem in either the short or the long term.
This article was translated from the Medscape French edition.