美国国家应急规划情景（2006）中文简译 之 情景3：生物学疾病暴发 – 大流行性流感
写在前面：情景构建是近年来公共安全管理领域最热门的专业方法之一，对应急准备规划、应急预案管理和应急培训演练等一系列应急管理工作实践具有不可或缺的支撑和指导作用，对企业的应急、连续性和危机管理也意义重大。为学习情景构建方法和推进企业级情景构建项目，我在今年3月份组织了一个公益翻译小组（小组成员征募链接： https://mp.weixin.qq.com/s/Ua-JgZUIUY4xHEbsN8qiXQ），对一些主要的情景构建资料进行翻译。7月份前后，翻译小组成员陆续将翻译文稿发送给我，近期我会将这些资料审校完成，陆续在公众号发布。
刘铁民在《重大突发事件情景规划与构建研究》一文中指出：《美国国家应急规划情景》（2006）由美国国土安全部组织了近1500名应急管理官员和来自大专院校与科研单位的科学家，经过一年多的调查研究，认真总结回顾了之前发生在美国和其他国家的重大突发事件典型案例，尤其是对未来可能发生重大突发事件的风险做了系统分析与评估，对可能发生事件的初始来源、破坏严重性、波及范围、复杂程度以及长期潜在影响作了系统归纳和收敛。经过反复多次评审和修改，总结提出15种重大突发事件情景是美国面临最严重的风险和挑战，这些情景被列为国家应急准备战略最优先考虑的应对目标。为强调对应急预案编制工作的指导性，又进一步把这15种重大突发事件情景整合集成为具有共性特点的8个重要情景组（如下表），使应急准备的重心更加聚焦。
| 重要情景组 | 国家预案编制情景 |
|---|---|
| 1.爆炸物攻击—使用自制爆炸装置进行爆炸 | 情景12：爆炸物攻击—使用自制爆炸装置进行爆炸 |
| 2.核攻击 | 情景1：核爆炸—自制核装置 |
| 3.辐射攻击—辐射扩散装置 | 情景11：辐射学攻击—辐射学扩展装置 |
| 4.生物学攻击—附病原体附件 | 情景2：生物学攻击—炭疽气溶胶 情景4：生物学攻击 情景13：生物学攻击—食品污染 情景14：生物学攻击—体表损伤皮肤疾病 |
| 5.化学攻击—附各种毒剂附件 | 情景5：化学攻击 情景6：化学攻击—有毒工业化学品 情景7：化学攻击—神经毒气 情景8：化学攻击-氯容品爆炸 |
| 6.自然灾害—附各种灾害附件 | 情景9：自然灾害—大地震 情景10：自然灾害—大飓风 |
| 7.计算机网络攻击 | 情景15：网络攻击 |
| 8.传染病流感 | 情景3：生物学疾病暴发—大流行性流感 |
本篇为《美国国家应急规划情景》（2006）中文简译的”情景3：生物学疾病暴发 — 大流行性流感”部分，以下译文由我负责翻译并审校定稿，如对译文有意见或修改建议，请给我留言。
王曙(kevinwang) 2024.12.05
情景3：生物学疾病暴发 – 大流行性流感 Scenario 3: Biological Disease Outbreak – Pandemic Influenza
| 项目 | 描述 |
|---|---|
| 伤亡情况 Casualties | 30%的发病率；死亡率和住院率因大流行病毒的毒性而有所不同：中度情景死亡人数约209,000，住院人数约865,000；重度情景死亡人数约190万，住院人数约990万 30% illness attack rate; fatalities and hospitalizations vary with virulence of the pandemic virus: moderate scenario 209,000 fatalities range and 865,000 hospitalizations; severe scenario 1.9 million fatalities, 9.9 million hospitalizations |
| 基础设施损坏 Infrastructure Damage | 无，但应强调基础设施的可持续性 None, however sustainability of infrastructure is stressed |
| 撤离与流离失所者 Evacuations/Displaced Persons | 无需疏散；在某些情况和社区中采取就地避难或隔离措施 No evacuation required; Shelter-in-place or quarantine used in some situations and communities |
| 污染情况 Contamination | 对患病人员进行隔离 Isolation of ill persons |
| 经济影响 Economic Impact | 无法估算包括经济活动和贸易在内的总成本。在没有干预的情况下，中度大流行的健康相关的直接和间接成本估计约1810亿美元 No estimate of the overall costs, including on economic activity and trade are available. An estimate of direct and indirect health-related costs, absent intervention, for a moderate pandemic is $181 billion |
| 多重事件的可能性 Potential for Multiple Events | 是的，病毒几乎同时在全国和全球范围内传播；第一年大流行期间出现第二波疾病 Yes, near simultaneous national and worldwide distribution; second wave of disease in first pandemic year |
| 恢复时间表 Recovery Timeline | 数月到1年以上 Several months to over 1 year |
3.1 情景概述 Scenario Overview：
3.1.1 一般描述 General Description —
流感大流行的发生不可预测，20世纪曾发生过三次（1918-1919年、1957-1958年和1968-1969年）。当一种新的甲型流感病毒亚型出现并导致人类感染（称为基因转移）时，就会出现流感大流行。如果这种在人群中几乎没有免疫力的新病毒亚型在人与人之间有效传播，就会造成大流行。虽然每年都会暴发甲型流感，但大流行是一个独特的事件。流感发病率及其严重程度可能会很高，因为大多数（或全部）人类群体都是易感人群。
Influenza pandemics occur unpredictably, with three occurring in the 20th century (1918-1919, 1957-1958, and 1968-1969). Influenza pandemics may occur when a new influenza A virus subtype emerges and causes infection in humans (referred to as genetic shift). If this new subtype, for which the population has little or no immunity, spreads efficiently between people, a pandemic may result. Although influenza A outbreaks occur annually, pandemics are distinct events. Rates of illness and severity of influenza can be high because most or all of the human population is susceptible.
20世纪流感大流行的经验差异显著：1918年大流行造成美国50多万人死亡；1957年大流行造成约7万人死亡；1968年大流行造成约3.4万人死亡。对于中度和重度大流行情景，大流行对健康、社会和经济功能以及应对活动的影响，将在数量和质量上有所不同。因此，为了更好地指导规划和准备工作，我们根据1918年大流型（重度）以及1957年和1968年大流行（中度）的经验提出了两种情景。无法预测每种情景或介于两者之间的情景发生的相对概率。
Experience with influenza pandemics during the 20th century varied markedly: the 1918 pandemic caused over 500,000 deaths in the United States; the 1957 pandemic caused about 70,000 deaths; and the 1968 pandemic caused about 34,000 deaths. For the moderate and severe pandemic scenarios, the health, social, and economic consequences of the pandemic, as well as response activities, will differ quantitatively and qualitatively. Consequently, to better guide planning and preparedness, two scenarios are presented based on the 1918 (severe) and the 1957 and 1968 (moderate) pandemic experiences. The relative probability of each scenario, or an event falling between the two, cannot be predicted.
3.1.2 详细情景 Detailed Scenario —
中度和重度大流行病毒的起源及初始传播可能相似，因此将其作为一个单一情景进行描述。一旦传播到美国后，这两种情景将被分别描述，因为它们对医疗保健和社会的影响将明显不同，需要不同的应对措施和能力。
The origin and initial spread of moderate and severe pandemic viruses may be similar and is presented as a single scenario. Once spread to the United States occurs, the scenarios are described separately because they will have distinctly different health and social consequences requiring different response measures and capabilities.
3.1.3 大流行情景 – 起源与初始传播 Pandemic Scenario – Origin and Initial Spread
在过去两年中，一种高致病性禽流感毒株在多个国家零星感染家禽。该病毒通过可能无症状感染的野生和迁移鸟类种群传播，感染的地理分布随着时间的推移而扩大。在与受感染家禽密切接触的人群中，也出现了零星的人类感染病例。世界卫生组织（WHO）已宣布”大流行警报”。为此，美国政府已开始研制和评估针对禽类病毒株的疫苗。抗病毒药物已被纳入国家战略储备（SNS），一些州和大城市地区也建立了储备。
For the past two years, a highly pathogenic avian influenza strain has sporadically infected domestic poultry in several countries. Spread by wild and migratory bird populations which may be asymptomatically infected, the geographic distribution of infection has increased over time. Sporadic human cases of infection have also occurred among persons in close contact with infected poultry. The World Health Organization (WHO) has declared a “pandemic alert.” In response, the U.S. Government has initiated efforts to develop and evaluate vaccine against the avian virus strain. Antiviral drugs have been added to the Strategic National Stockpile (SNS), and some States and large metropolitan areas have also established stockpiles.
当年2月下旬，一个国家的一个小村庄暴发了严重的呼吸道疾病，据悉该国最近曾发生过禽流感疾病。至少出现了25例病例，各年龄组均有感染。发现了多个家庭成员受到感染的家庭群。20名患者需要在当地省级医院住院治疗，其中5人死于肺炎和呼吸衰竭。病例最初由国家卫生部门负责调查，但3月中旬，在邻近村庄和省会发现新病例后，请求世界卫生组织（WHO）提供援助。从几名患者身上采集的样本被送往世界卫生组织流感合作中心实验室进行亚型鉴定。
In late February of the current year, an outbreak of severe respiratory illness is identified in a small village in a country known to have experienced recent avian influenza disease. At least twenty-five cases occur among persons in all age groups. Family clusters are identified, with multiple family members affected. Twenty patients require hospitalization at the local provincial hospital; five die from pneumonia and respiratory failure. Initially investigated by national health authorities, WHO assistance is requested in mid-March when new cases are identified in neighboring villages and provinces. Samples from several patients are sent to a WHO influenza collaborating center laboratory for subtype identification.
这种新型流感病毒开始成为各大报纸的头条新闻，并成为各大新闻网络的头条新闻。美国政府的主要官员每天都会听取简报，包括美国在内的许多国家都加强了监测。各州卫生部门加强流感监测系统，并开始对新亚型进行诊断检测。CDC、FDA和其他实验室开始从新菌株分离物中开发用于疫苗生产的参考菌株；美国国立卫生研究院（NIH）研究针对禽病毒菌株开发的疫苗是否能在一定程度上抵御这种大流行病毒；流感疫苗生产商进入警戒状态。
The novel influenza virus begins to make headlines in every major newspaper and becomes the lead story on major news networks. Key U.S. Government officials are briefed on a daily basis, and surveillance is stepped up in many countries, including the United States. State health departments intensify influenza surveillance systems and begin diagnostic testing for the new subtype. CDC, FDA, and other laboratories begin developing reference strains for vaccine production from the new strain isolate; NIH studies whether vaccine developed against the avian virus strain offers some protection against this pandemic virus; and influenza vaccine manufacturers go on alert.
在接下来的两个月（3月和4月），世界卫生组织在美国和其他国家政府的协助下，试图遏制疫情暴发，但新的病例不断出现，并向邻国蔓延。与疫区有广泛贸易往来的较远国家也发现了病例和小规模疫情暴发。据报告，所有年龄组都有病例，死亡率从2%到15%不等，具体取决于医疗质量。边境和检疫站对疫区实施了旅行限制，并对入境旅客进行发热疾病监测。5月初，CDC报告称，已在抵达美国四个主要城市的患病航空公司乘客中分离出该病毒。
Over the next two months, March and April, WHO with assistance from the U.S. and other governments, attempts to contain the outbreak, but new cases continue to occur and to spread to neighboring countries. Cases and small outbreaks also appear in more distant countries having extensive trade with the region. Cases are reported in all age groups, with mortality ranging from 2 to 15 percent, depending on the quality of medical care. Travel restrictions to the affected area are implemented at borders and points of entry, and febrile travelers are screened. In early May, CDC reports isolating the virus from ill airline passengers arriving at four major U.S. cities.
6月和7月，美国各地开始报告小规模局部疫情暴发。8月，第一批新的大流行疫苗开始供应。尽管制造商已全面生产，但供应量仍然非常有限。私营部门提供的所有流感抗病毒药物都被病人或相关个人和组织购买；因此，仅有的供应是国家和各州的储备，但数量有限。随着儿童返校，社区范围的疫情暴发开始变得更加频繁，到9月下旬，全国各地同时暴发疫情。
In June and July, small focal outbreaks begin to be reported throughout the United States. The first doses of a new pandemic vaccine become available in August. Despite full-scale production by manufacturers, supplies remain very limited. All privately held influenza antiviral drugs are purchased by ill persons or concerned individuals and organizations; thus, the only remaining supplies are national and State stockpiles, which are limited. As children return to school in the fall, community-wide outbreaks begin to occur more frequently, and by late September, simultaneous outbreaks are occurring across the country.
3.1.4 重度（类似1918年）大流行的后续情景 Scenario Continued for Severe (1918-like) Pandemic –
对初始暴发的流行病学调查发现，婴儿、成年人和老年人的住院率和死亡率最高。总体上，约有2%的美国流感患者死亡。在社区，流感暴发的高峰期长达6-8周，约有四分之一的工人因生病、需要照顾生病的家属以及害怕在公共场所或工作场所被感染而缺勤。在疫情最严重的时候，医院不堪重负，人员短缺限制了医疗能力。地方医院的重症监护室无法为所有需要的人提供治疗，治疗重症肺炎和呼吸衰竭患者的机械呼吸机短缺。在学校和军械库建立了临时医院。
Epidemiological investigation of initial outbreaks determines that rates of hospitalization and death are greatest among infants, adults, and the elderly. Overall, about 2% of Americans with influenza die. In communities, influenza outbreak peaks last 6-8 weeks, and approximately one-quarter of workers are absent from work because they are ill, need to care for ill family members, and are afraid of becoming infected in public places or the workplace. At the peak of the outbreak, hospitals are overwhelmed and staff shortages limit the capacity of care. Local hospital ICUs cannot treat all those in need, and mechanical ventilators to treat patients with severe pneumonia and respiratory failure are in short supply. Temporary hospitals are set up in schools and armories.
在社区疾病活动高峰期，警察、消防和运输服务因人员短缺而受到限制，公用事业公司的员工缺勤导致局部停电。由于卡车司机生病或待在家里不工作，食品、燃料和医疗用品的供应受到干扰。在一些地区，杂货店货架空空如也，社会动荡随之而来。有食物和汽油供应的地方都排起长队。患有慢性病、病情不稳定的老年病人因为害怕感染流感而病入膏肓，不敢出门。一些疫苗接种诊所发生骚乱，因为人们被拒之门外或疫苗供应告罄。几辆运送疫苗的卡车被劫持。
During the peak of disease activity in communities, police, fire, and transportation services are limited by personnel shortages, and absenteeism at utility companies leads to spot power outages. Supplies of food, fuel, and medical supplies are disrupted because truck drivers are ill or stay home from work. In some areas, grocery store shelves are empty and civil unrest follows. Long lines form where food and gasoline are available. Frail elderly patients with chronic, unstable health conditions stay home, afraid of contracting influenza. Riots occur at some vaccination clinics, as people are turned away or vaccine supplies run out. Several trucks carrying vaccines are hijacked.
3.1.5 中度（类似1957年或1968年）大流行的后续情景 Scenario Continued for Moderate (1957- or 1968-like) Pandemic –
对初始疫情暴发的流行病学调查后发现，婴儿和老年人的住院率和死亡率最高。总体上，每千名流感患者中约有3名（0.3%）美国人死亡。在社区，流感暴发高峰期持续6-8周，约有10%的工人因生病或需要照顾生病的家属而缺勤。医院通过在走廊上摆放病床来扩大收治能力，医护人员实行12小时轮班制。许多地方医院的重症监护室不堪重负，用于治疗重症肺炎和呼吸衰竭患者的机械呼吸机短缺。
Epidemiological investigation of initial outbreaks determines that rates of hospitalization and death are greatest among infants and the elderly. Overall, about three of every thousand (0.3%) Americans with influenza die. In communities, influenza outbreak peaks last 6-8 weeks, and approximately 10% of workers are absent from work because they are ill or need to care for ill family members. Hospitals expand capacity by placing beds in hallways, and health care workers work 12-hour shifts. Many local hospital ICUs are overwhelmed, and mechanical ventilators to treat patients with severe pneumonia and respiratory failure are in short supply.
在社区疾病活动的高峰期，每10名工人就有1名缺勤，因此其余的工人会延长工作时间，主管与一线工作人员一起工作。警察、消防、交通和公共事业服务总体得以维持，但在受灾特别严重的地区，也发生了几起广为人知的崩溃事件。一些患有慢性病、病情不稳定的老年病人因害怕感染流感而病入膏肓，不敢出门。疫苗供不应求，但公共秩序得以维持。疫苗和抗病毒药物的灰色市场逐渐形成，其中许多是假药。病例高峰出现在10月下旬；到12月，病例数已降至基准水平。
As 1 in 10 workers is absent during the peak of disease activity in communities, remaining workers expand their hours, and supervisors work alongside frontline staff. Police, fire, transportation, and utility services are generally maintained, although several well-publicized breakdowns occur in particularly hard-hit areas. Some frail elderly patients with chronic, unstable health conditions stay home, afraid of contracting influenza. Vaccine is in short supply, but public order is maintained. A gray market for vaccine and antiviral drugs emerges; many of the drugs are counterfeit. Peak case incidence occurs in late October; by December, case incidence has fallen to baseline levels.
3.2 规划考虑因素 Planning Considerations：
3.2.1 地理考虑因素/描述 Geographical Considerations/Description —
在人与人之间传播的新型流感亚型的最初可能出现在任何国家。最近的大流行毒株起源于亚洲，亚洲的H5N1禽流感是当前最大的大流行威胁。然而，1918年大流行可能起源于美国，最近在欧洲、加拿大和美国暴发的其它致病性禽流感菌株也造成了人类感染，这说明了大流行的地理起源并不确定。
The initial emergence of a new influenza subtype that spreads between people can occur in any country. The most recent pandemic strains have originated in Asia, and the H5N1 avian influenza in Asia represents the current greatest pandemic threat. However, the 1918 pandemic may have originated in the United States, and other recent outbreaks of highly pathogenic avian influenza strains in Europe, Canada, and the United States that have caused human infections illustrate the uncertainty of geographic origin.
如果遏制初期暴发的努力失败，大流行性流感疾病将在全球蔓延。邻国和有广泛旅行/贸易联系的国家将首先受到影响。与过去的大流行相比，广泛的国际旅行将加速传播。一旦美国开始出现基于社区的疫情暴发，鉴于美国国内旅行量巨大，全国性的传播将非常迅速。大城市地区可能最早受到影响，但在一到两个月内，几乎所有社区都会出现疫情。一些偏远社区可能会通过全面限制外部人员进入社区来防止疾病传入，但这种情况极为罕见。由于所有地区同时发生疫情，受灾严重地区的资源无法提供给其他地区的响应工作。
If efforts to contain the initial outbreak fail, pandemic influenza disease will spread globally. Neighboring countries and those sharing extensive travel/trade links will be affected first. Extensive international travel will accelerate spread compared to past pandemics. Once community-based outbreaks begin in the United States, transmission throughout the country will be very rapid given the volume of domestic travel. Large metropolitan areas may be affected earliest, but within one to two months, nearly all communities will experience outbreaks. Some remote communities may prevent introduction by completely restricting entry of outside people into the community, but this will be rare. Because all regions will experience outbreaks simultaneously, resources from hard-hit areas cannot be made available to response efforts in other areas.
在国际层面上，医疗资源有限、国内不生产流感疫苗、几乎没有抗病毒药物储备的国家可能会请求美国及其他工业化国家提供援助。然而，目前美国流感疫苗生产能力、药物生产和储备方面的限制，以及相关医疗设备的有限库存，将使其极难甚至不可能应国际请求提供任何物资。如果无法满足发展中国家提出的相关援助请求，哪怕是其中的一部分，也很可能会产生显著的国际政治影响。
On an international level, countries with limited health care resources, no domestic influenza vaccine production, and little to no stockpiled antiviral drugs will likely request aid from the United States and other industrialized countries. However, current U.S. limitations on influenza vaccine production capacity, drug production and stockpiling, and limited inventory of associated medical equipment will make it extremely difficult or impossible to fulfill any requests for materiel. If requests for aid from developing countries cannot be met, even in part, there will likely be significant international political repercussions.
3.2.2 时间线/事件动态 Timeline/Event Dynamics —
附录3-A提供了1957-1958年流感大流行在美国和美国境内传播的时间表。从识别出由人与人之间传播的新流感亚型引发的初始疫情与在美国发生大规模疫情之间的时间尚不清楚，这取决于几个因素。这些因素包括初始疫情暴发的地点（例如，偏远农村地区或城市交通枢纽）、发现的早晚、围绕最初病例和疫情暴发实施的遏制措施的影响、旅行限制和筛查的有效性以及季节。数学建模的结果表明，旅行限制和筛查，即使它们的有效率达到90%以上，最多也只能将大流行性流感的传入延迟几周。
Appendix 3-A provides a timeline for spread of the 1957-1958 influenza pandemic to, and within, the United States. The amount of time between recognition of an initial outbreak caused by a new influenza subtype that is transmitted between people and the occurrence of widespread disease in the United States is unknown and depends on a number of factors. These include the location of the initial outbreak (e.g., remote rural area or urban transportation hub), how early it is detected, the impact of containment measures implemented around the initial cases and outbreaks, the effectiveness of travel restrictions and screening, and the season. Results of mathematical modeling indicate that travel restrictions and screening, even if they are greater than 90% effective, can at best delay the introduction of pandemic influenza by only a few weeks.
美国与以往大流行相关的大规模疾病浪潮发生在秋冬季节。例如，1957年6月和7月期间，军营和其他封闭环境中发生了聚集性病例。直到8月儿童返校才发生社区疫情，第一波疾病在10月中旬达到顶峰。然而，过去的经验太有限，无法支持对夏季不会发生疾病浪潮的自信预测。社区大流行性流感暴发通常持续约6至8周。
Large disease waves in the United States associated with prior pandemics occurred in the fall and winter. In 1957, for example, clusters of cases occurred in military camps and other closed settings during June and July. Community outbreaks did not occur until August when children returned to school, and the first wave of illness peaked in mid-October. However, past experience is too limited to support confident predictions that disease waves will not occur in summer. Community pandemic influenza outbreaks typically last about 6 to 8 weeks.
大流行性疾病传播到美国的速度很重要，因为生产出第一剂新的大流行疫苗至少需要三到六个月的时间。在大流行开始后6个月内，将需要6亿剂（每人两剂）的国内疫苗激增生产能力。然而，由于美国目前的疫苗生产能力有限，即使有部分剂量可用，绝大多数人口也无法在大流行到来之前获得疫苗。因此，必须有一种机制在人群中分配疫苗——决定哪些人群可以优先接种。
The speed at which the pandemic disease spreads to the United States is important, because it will take at least three months and up to six months before the first doses of a new pandemic vaccine are produced. Within 6 months of the pandemic onset, a surge production capacity of 600 million doses (2 per person) would be needed domestically. However, with current U.S. vaccine production capacity, even with partial dose availability, the vast majority of the population would not be able to receive vaccine before the pandemic arrives. Therefore, there must be a mechanism for allocating vaccine among the population—determining which groups will receive priority for vaccination.
3.2.3 假设 Assumptions —
对大流行性流感亚型的易感性将是普遍的。 Susceptibility to the pandemic influenza subtype will be universal.
临床疾病发病率：30%（学龄儿童发病率最高[40%]；随着年龄的增长，发病率下降[工作年龄段成人20%]）。
Clinical disease attack rate: 30% (highest rate among school aged children [~ 40%]; declining rates with age [~ 20% among working aged adults]).
寻求门诊医疗护理的人数：约占患者的50%。 Number seeking outpatient medical care: 50% of those who are ill.
住院人数：取决于大流行病毒的毒力。由于无法预测，因此根据过去的大流行经验，提出了两种情景（见表3-1和3-2）。 Number of hospitalizations: depends on the virulence of the pandemic virus. Because this cannot be predicted, two scenarios are presented based on past pandemic experience (Tables 3-1 and 3-2).
未经治疗的疾病死亡率：0.2%至2%。 Untreated disease case-fatality rate: 0.2% to 2%.
潜伏期：1-4天（平均2天）。 Incubation period: 1-4 days (average 2 days).
二次传播率：每个原发感染者传染2个继发感染者。 Secondary transmission rate: two secondary infected persons per primary infected person.
应对措施的可用性： Countermeasure availability:
疫苗：在大流行之前，可能会储备数百万剂部分有效的疫苗并可供使用。新的大流行疫苗需要3-6个月才能生产出来。在目前的生产能力下，每月将提供足够的剂量来为0.25%至1%的人口进行免疫接种。 Vaccine: several million doses of partially effective vaccine may be stockpiled and available before the pandemic. New pandemic vaccine will take 3-6 months to produce. At current production capacity, enough doses will become available each month to vaccinate 0.25% to 1% of the population.
抗病毒药物：流感抗病毒药物已纳入国家战略储备。目前的目标是2000万个疗程。一些州还在建立储备。美国目前的产量约为每月120万个疗程。 Antiviral drugs: influenza antiviral drugs are included in the SNS. A current target is 20 million treatment courses. Some States also are establishing stockpiles. Ongoing U.S.-based production will be about 1.2 million treatment courses per month.
3.2.4 激活的使命领域 Mission Areas Activated —
3.2.4.1 预防/威慑： 大多数科学家认为流感大流行不可避免。努力减少流感在动物中的传播，降低人类和动物流感毒株共同感染人或动物并形成新的大流行性病毒的风险，可能会降低风险。这可能会延缓下一次大流行发生之前的时间。监测动物流感并在发现感染时迅速实施控制措施非常重要。每年接种流感疫苗可降低大流行风险，并可刺激流感疫苗产量的增加，提高应对大流行的能力。
Prevention/Deterrence: Most scientists consider influenza pandemics inevitable. Efforts to decrease the spread of influenza in animals, and to decrease the risk that human and animal influenza strains will co-infect a person or an animal and produce a new pandemic virus, may reduce risk. This could lengthen the time before the next pandemic occurs. Monitoring influenza in animals and quickly instituting control measures when infection is detected is important. Annual influenza vaccination could reduce pandemic risk and may stimulate increased influenza vaccine production, improving pandemic response capacity.
当出现一种新的能够在人与人之间高效、持续地传播的新型甲型流感亚型时，遏制（即”扑灭火花”和防止大流行）将变得极为困难。数学模型表明，将早期发现和快速反应与有效的病例检测、对潜在接触者和邻近人群的抗病毒治疗和预防、减少人与人之间接触的措施以及疫苗接种（如果有）结合起来，可以防止大流行。然而，监测的敏感性和贫穷国家采取有效应对措施的能力是成功遏制大流行的障碍。关于美国在多大程度上参与世界卫生组织（WHO）的全球疫情警报和反应网络（Global Outbreak Alert and Response Network）以及其他能力建设活动，将决定美国协助遏制国际疫情的能力和意愿。
When a new influenza A subtype emerges that is capable of efficient and sustained transmission between people, containment (“putting out the spark” and preventing a pandemic) will be extremely difficult. Mathematical modeling suggests that combining early detection and rapid response with effective case detection, antiviral treatment and prophylaxis of potential contacts and adjacent populations, measures to decrease person-to-person contact, and vaccination, if available, could prevent a pandemic. However, the sensitivity of surveillance and the capacity of poorer countries to mount an effective response present obstacles to successful containment. The extent to which the United States participates in the WHO Global Outbreak Alert and Response Network and other capacity building activities will determine its ability and willingness to assist in containing an international outbreak.
3.2.4.2 准备： 准备活动在一系列领域都至关重要。加强全球监测，及早发现可在人与人之间感染和传播的新亚型，将有助于遏制疫情和及早开发大流行疫苗。疫苗准备工作包括：扩大美国的生产能力；开发新的生产方法；改进疫苗以增强免疫反应；以及缩短生产新疫苗的时间。目前正在储备抗病毒药物，并考虑储备针头/注射器、个人防护装备（PPE）和口罩等其他基本材料。
Preparedness: Preparedness activities are critical across a range of areas. Improved global surveillance and earlier detection of new subtypes that infect and spread between people will facilitate containment and earlier development of pandemic vaccine. Vaccine preparedness includes: expanding production capacity in the U.S.; developing new production methods; improving vaccines to increase the immune response; and reducing the time required to produce a new vaccine. Antiviral drugs are being stockpiled, and other essential materials such as needles/syringes, personal protective equipment (PPE), and masks are being considered for stockpiling.
在卫生资源和服务管理局（HRSA）合作协议的支持下，医疗保健系统准备工作的目标包括将医院床位容量增加15%-20%，在地方医院和医疗保健组织之间进行协调；以及开展教育和培训。对大流行暴发高峰周的医疗负担估计表明，在中等大流行中，大约需要25%的医院床位和近40%的重症监护室（ICU）床位来照顾流感患者。据估计，重度大流行的需求量将增加约10倍，医院和ICU的护理需求量将超过当前医院床位的100%。因此，应对更严重的大流行的准备工作需要有质的不同，并包括大规模扩大提供类似医院护理能力的战略，例如通过利用学校、军械库和其他设施来建立临时医院。
Targets for health care system preparedness, supported by a Health Resources and Services Administration (HRSA) cooperative agreement, include increasing staffed hospital bed capacity by 15%-20%, coordination between local hospitals and health care organizations; and conducting education and training. Estimates of the health care burden during the peak week of a pandemic outbreak indicate that approximately 25% of hospital beds and nearly 40% of intensive care unit (ICU) beds would be needed to care for influenza patients in a moderate pandemic. Demand for a severe pandemic is estimated to be about 10-fold greater, with hospital and ICU care demands exceeding 100% of current hospital bed capacity. Preparedness for a more severe pandemic thus is qualitatively different and includes strategies for massively expanding capabilities to provide hospital-like care, e.g., through use of schools, armories, and other facilities for use as temporary hospitals.
研究可以开发新的干预措施和能力，从而改善大流行的应对措施。例如，通过添加佐剂或皮下注射疫苗来改变疫苗配方，可能改善免疫反应，减少每剂疫苗所需的抗原量，并有可能将现有生产能力所能生产的剂量增加数倍。关键的研究活动还包括开发新的抗病毒药物、开发改进的诊断测试以及评估最佳临床管理策略。更完整的大流行性流感准备研究和开发活动清单另行发布。通过鼓励制造商提高生产能力、加强疫苗交付基础设施和公众对流感疫苗的接受度，提高年度流感疫苗的接种率也将有助于大流行准备工作。
Research can lead to the development of new interventions and capabilities that will improve a pandemic response. For example, modifying vaccine formulations by adding an adjuvant or administering vaccine intradermally may improve the immune response, reduce the amount of antigen required per dose, and potentially multiply several-fold the number of doses that can be produced with current manufacturing capacity. Key research activities also include developing new antiviral drugs, developing improved diagnostic tests, and evaluating optimal clinical management strategies. A more complete list of pandemic influenza preparedness research and development activities is available elsewhere. Increasing annual influenza vaccination rates also will aid pandemic preparedness efforts by encouraging manufacturers to increase production capacity, strengthening the vaccine delivery infrastructure, and increasing public acceptance of influenza vaccination.
3.2.4.3 应急评估/诊断： 调查由新型流感病毒亚型引起的人类疾病的最早暴发（无论这种暴发发生在美国还是海外），对于提供有关风险群体、临床过程、传播和治疗的信息非常重要。对大流行病毒株进行实验室调查对于开发疫苗和诊断测试以及评估抗病毒药物敏感性至关重要。数学建模人员正在确定在大流行早期需要收集的一系列关键数据，以便对干预策略及其影响进行实时建模。
Emergency Assessment/Diagnosis: Investigation of the earliest outbreaks of human disease caused by a new influenza virus subtype—whether such outbreaks occur in the United States or overseas—is important to provide information on risk groups, clinical course, transmission, and treatment. Laboratory investigation of the pandemic virus strain is essential for development of vaccines and diagnostic tests, and for evaluating antiviral drug susceptibility. Modelers are identifying a core set of data that needs to be collected early in the pandemic to allow real-time modeling of intervention strategies and their effects.
大流行期间，大多数流感病例的诊断将是临床诊断。快速测试的灵敏度不够，不能作为管理决策的依据，实验室进行更明确检测的能力很快就会被淹没。目前的监测基础设施包括由哨点医生报告病情；报告几个地理区域的儿童住院情况；使用死亡证明数据进行死亡率监测；以及州级流感活动强度评估。在大流行中，这些系统将得到来自医院的发病率和死亡率报告的补充。需要努力确保做到这一点。还将开展更多的调查，以确定哪些人受到感染、发展为重症或死亡的流行病学情况。
Diagnosis of most influenza cases during a pandemic will be clinical. Rapid tests are insufficiently sensitive to be used as a basis for management decisions, and laboratory capacity for more definitive testing would quickly be overwhelmed. Current surveillance infrastructure includes reports of illness from sentinel physicians; reporting of hospitalizations of children in several geographic regions; mortality surveillance using death certificate data; and State-level assessments of influenza activity intensity. In a pandemic, these systems would be supplemented by reports of morbidity and mortality from hospitals. Efforts to ensure that this is possible need to be undertaken. Additional investigations would be conducted to determine the epidemiology of who becomes infected, develops severe disease, or dies.
3.2.4.4 应急管理/响应： 大流行期间应急管理的有效性将取决于大流行前的规划和准备的程度以及大流行的严重程度。联邦政府正在完成大流行准备和应对计划，所有州都已完成了计划草案。许多州还进行了准备演练。由于国家指导意见不够具体，而且在抗病毒药物储备的可用性以及大流行疫苗的所有权和分配方面存在不确定性，因此规划工作受到了阻碍。在州和社区层面实施大流行应对活动的具体计划还需要大量的工作。
Emergency Management/Response: The effectiveness of emergency management during a pandemic will depend on the degree of pre-pandemic planning and preparation and on the severity of the pandemic. The Federal government is completing a pandemic preparedness and response plan, and all States have completed draft plans. Many States have also conducted preparedness exercises. Planning has been hampered by a lack of specific national guidance and uncertainty about the availability of antiviral drug stockpiles and ownership and distribution of pandemic vaccine. Significant additional work to develop specific plans for implementing pandemic response activities at the State and community level is needed.
中度和重度大流行对关键基础设施和社会功能的影响会明显不同。1957年或1968年没有发生重大社会混乱，尽管社会的复杂性和网络化程度的提高使得在中度大流行中出现单一程度的混乱成为可能。像1918年那样严重的大流行可能会对社区服务和商业活动造成严重破坏。在重度大流行中，应急管理需要包括建立临时医院、运送病人、为居家病人提供护理和服务、在现有能力不堪重负时处理尸体、维护社区、疫苗接种和医疗护理场所的安全，以及确保提供公用事业和其他基本服务。由于大流行将影响所有地区，因此无法集中应急管理人员和资源（参见地理因素部分）。
Pandemic impacts on critical infrastructure and societal functions will be markedly different for moderate and severe pandemics. No significant societal disruption occurred in 1957 or 1968, although the increased complexity and networking in society makes single-order disruption possible in a moderate pandemic. A pandemic as severe as that of 1918 would likely severely disrupt community services and business activities. In a severe pandemic, emergency management would need to include establishing temporary hospitals, transporting patients, providing care and services for people who are homebound, handling fatalities when existing capabilities are overwhelmed, maintaining security at community, vaccination, and medical care sites, and ensuring provision of utilities and other essential services. Because all regions will be affected by the pandemic, a centralized pool of emergency managers and resources will not be available (see Geographic Considerations section).
3.2.4.5 灾害缓解： 灾害缓解的成功将取决于规划和准备的水平，储备资源的可用性，大流行性疾病在美国大范围传播前的预警时间，以及大流行的严重程度。由于为潜在的大流行毒株储备疫苗的好处不确定，而且大流行疫苗的生产能力有限，大多数疾病病例将无法预防。在中度大流行中，医疗保健系统的质量和社区服务可能会得以维持，从而减轻健康和社会的影响。在重度大流行中，对医疗保健服务的需求和关键基础设施的工人缺勤可能导致崩溃。为中度和重度大流行情景进行规划对于降低这种风险非常重要。
Hazard Mitigation: The success of hazard mitigation will depend on the level of planning and preparedness, the availability of stockpiled resources, the duration of warning before widespread pandemic disease in the United States, and the severity of the pandemic. Because the benefits of stockpiling vaccine for the potential pandemic strain are uncertain and pandemic vaccine production capacity is limited, most disease cases will be unpreventable. In a moderate pandemic, the quality of the health care system and community services may be maintained, thus mitigating health and social consequences. In a severe pandemic, demands on health care services and worker absenteeism in critical infrastructure may cause collapse. Planning for both moderate and severe pandemic scenarios is important to reduce this risk.
实施公共卫生措施，如关闭学校、取消公共集会、在公共场所佩戴口罩和鼓励洗手等，在限制受影响社区内大流行病的范围方面的价值不确定；不过，许多社区可能会实施这些措施。“雪天模式”（即人们待在家里不上学或不上班），可能会限制疾病的传播，但会导致严重的经济混乱。除了最偏远的社区外，限制旅行不太可能带来好处，而且会对经济造成重大影响。
Implementation of public health measures, such as closing schools, canceling public gatherings, wearing masks in public, and encouraging hand washing, are of uncertain value in limiting the extent of pandemic disease within affected communities; nevertheless, many communities may implement such measures. “Snow days” (days when people stay home from school or work) may limit spread of disease but cause significant economic disruption. Travel restrictions are unlikely to provide benefits except in the most isolated communities and would cause major economic disruption.
向公众有效传达信息是灾害缓解的重要组成部分。最近的突发公共卫生事件，如2001年10月的炭疽邮件袭击和2003年的严重急性呼吸系统综合征（SARS）疫情，都表明公众的反应在一定程度上取决于以下因素：
- 所提供的公共卫生信息的类型；
- 这些信息被认为和实际的可靠性和科技”合理性”；
- 信息来源；以及
- 信息的及时性。
Effective communication of information to the public is an important component of hazard mitigation. Recent public health emergencies, such as the anthrax-letter attacks in October 2001 and the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic, demonstrate that the public response depends in part on:
- The type of public health information provided;
- The perceived and actual reliability and scientific “soundness” of such information;
- The source of the information; and
- The timeliness of the information.
3.2.4.6 疏散/庇护： 疏散不会对对疾病的传播产生有意义的影响，反而会将感染扩散到尚未受影响的地区，并使不久可能暴发疾病的地区的服务负担过重。如果不需要医院护理，让患病人员居家隔离可以减少感染的传播，但需要确保可以按需提供医疗和其他服务。由于潜伏期短（1-4天）且无症状患者传播疾病的能力，隔离接触者不太可能影响流感的传播。
Evacuation/Shelter: Evacuations will have no meaningful effect on the spread of disease and may be counter-productive by spreading infection to as yet unaffected areas and by overburdening services in a site that soon is likely to experience an outbreak of disease. Isolation of ill persons at home can reduce transmission if they do not require hospital care, provided that medical and other services can be delivered as needed. Quarantine of contacts is unlikely to affect influenza transmission because of the short incubation period (1-4 days) and the ability of asymptomatic persons to transmit the disease.
3.2.4.7 受害者关怀： 在中度和重度大流行中，大多数患病人员都将在门诊接受非处方药治疗。抗病毒药物将用于门诊患者和住院患者之间特定目标群体的治疗。由于在疾病早期开始抗病毒治疗的有效性更高，因此需要从门诊、急诊室和其他护理点分发药物。
Victim Care: In both moderate and severe pandemics, most ill persons will be treated as outpatients with over-the-counter medications. Antiviral drugs will be used for treatment in defined target groups among both outpatients and those admitted to hospital. Because the effectiveness of antiviral therapy is greater when treatment is started early in the illness, access to the drugs will need to be available from outpatient clinics, emergency rooms, and other points of care.
在中等大流行情景中，只有不到1%的患病人员需要住院治疗；而在更严重的情景中，近10%的病人需要住院。治疗将主要为支持性治疗。肺炎患者可能需要补充氧气，包括机械通气。在重度大流行中，可能会出现呼吸机短缺。继发性细菌性肺炎常常是流感的并发症，可能由耐药病原体引起。对于高度耐药菌株，可能缺乏有效的抗生素（例如万古霉素）。患者护理也可能因其他医院用品短缺而受到影响，尤其是在更严重的大流行中运输系统中断的情况下（请注意，医院的库存有限，依赖每天运送的物资）。为防止流感在医院内传播，感染患者将被隔离，或者当隔离能力不足时，将与其他患者安置在不同区域。
In the moderate pandemic scenario, less than 1% of ill persons will require hospital care, whereas in the more severe scenario, almost 10% will require admission. Treatment will primarily be supportive. Patients with pneumonia may require supplemental oxygen, including mechanical ventilation. In a severe pandemic, ventilator shortages are likely. Secondary bacterial pneumonia, a common complication of influenza, may be caused by resistant pathogens. Effective antibiotics may not be available for highly resistant strains (e.g., vancomycin). Patient care could also be compromised by shortages of other hospital supplies, especially if transportation systems are disrupted in a more severe pandemic (note that hospitals maintain limited inventories and rely on daily deliveries). To prevent the spread of influenza within hospitals, infected patients will be isolated or, if isolation capacity is inadequate, cohorted with other patients.
还需要制定计划，处理在相对较短的时间内出现的大量死亡事件。殓房和殡葬服务可能会超负荷运转，导致殡葬服务延误，这反过来又会加重丧亲家庭的痛苦。
There is also a need to plan to deal with the large number of fatalities that will occur in a relatively short period of time. Mortuary and burial services may become over-extended, causing delays in funeral services; this, in turn, will heighten the distress of bereaved families.
由于大流行将是全球性的，美国国务院将为在海外旅行或居住的美国公民提供适当的援助，包括及时发布信息，使公民能够做出明智的计划和决定。
Since a pandemic will be global in scope, the U.S. Department of State will provide appropriate assistance to U.S. citizens traveling or residing abroad, including the timely dissemination of information to allow citizens to make informed plans and decisions.
3.2.4.8 调查/抓捕： 对于大流行性流感，调查包括临床与流行病学研究以及疾病监测。目前的流感监测系统（见应急评估/诊断部分所述）具有明显的局限性。
Investigation/Apprehension: For pandemic influenza, investigation includes clinical and epidemiological studies and disease surveillance. The current influenza surveillance system, described in the Emergency Assessment/Diagnosis section, has distinct limitations.
3.3 影响 Implications：
3.3.1 次生危害/事件 Secondary Hazards/Events —
最大的次生危害将是医疗用品（例如疫苗和抗病毒药物）、设备（例如机械呼吸机）、医院床位和医护人员短缺造成的问题，这些问题可能会因供应链中断以及运输和电信等基本服务的减少而加剧。建立详细的资源分配和维持医疗用品供应的系统可能会减少这种困难。该系统应该在流感大流行实际发生之前就已经到位。
The greatest secondary hazard will be the problems caused by shortages of medical supplies (e.g., vaccines and antiviral drugs), equipment (e.g., mechanical ventilators), hospital beds, and health care workers—potentially exacerbated by resulting disruptions in supply chains and reductions in essential services such as transportation and telecommunications. A system for detailed resource allocation and for maintaining the availability of medical supplies may reduce this difficulty. The system should be in place, ideally, before an influenza pandemic occurs.
特别令人担忧的是医疗保健系统，尤其是医院，可能会不堪重负。减轻这种影响的一种方法是制定计划，在入院患者之间有效地分配稀缺的医院资源。这将要求根据需要、资源可用性和预期结果对新患者进行分类。实际上，在流感大流行期间，医院工作人员和患者将不得不接受不同的护理标准。例如，必须降低护士与床位的比例，这意味着每个护士都必须照顾更多的床位。没有资格的工作人员和志愿者将提供一些护理，患者可能无法获得他们和他们的医生通常期望使用的所有治疗，例如机械通气。在学校或其他环境中建立的临时医院不太可能提供与常规设施相同水平的护理。
Of particular concern is the likelihood that health care systems, particularly hospitals, will be overwhelmed. One method of mitigating such an impact is to have plans in place that effectively allocate scarce hospital-based resources among incoming patients. This would require triaging new patients based on need, resource availability, and expected outcome. In practice, hospital staff and patients would have to accept different standards of care during a flu pandemic. For example, the nurse-to-bed ratio would have to be reduced, meaning each nurse would have to care for more beds. Unqualified staff and volunteers would provide some care, and patients might not have access to all the treatments they and their physicians would normally expect, such as mechanical ventilation. Temporary hospitals established in schools or other settings are unlikely to provide the same level of care as a regular facility.
除了在大流行最严重阶段引起的急性焦虑外，还会有其他行为健康问题。医务人员和物资的严重短缺意味着人们将无法获得精神药物、美沙酮或其他需要的药物。高度脆弱的人群，例如人类免疫缺陷病毒（HIV）感染者，将受到独特的影响。
In addition to the acute anxiety caused during the most severe phases of the pandemic, there will be other behavioral health concerns. Severe shortages in medical personnel and supplies mean that people will not be able to obtain psychotropic medications, methadone, or other needed drugs. Highly vulnerable populations, such as persons living with human immunodeficiency virus (HIV), will be uniquely affected.
另一个重要的次生危害是在更严重的大流行中可能发生的社会混乱。学校和工作场所等机构可能会因为大部分学生或员工生病而关闭，或者作为一项公共卫生措施为减少疾病在这些环境和社区中的传播而关闭。基本服务可能会受到限制，因为员工因疾病、需要照顾生病的家庭成员或害怕在工作中被感染而缺勤。网络、供应链和及时库存的复杂性使得某些群体的缺勤可能会引发连锁反应，影响范围更广。关键行业制定包括交叉培训员工在内的业务连续性计划可能会降低这种风险。
Another important secondary hazard is the disruption that might occur in society in a more severe pandemic. Institutions, such as schools and workplaces, may close because a large proportion of students or employees are ill or may close as a public health measure to reduce disease transmission in these settings and communities. Essential services may be limited because employees are absent due to illness, the need to care for ill family members, or fear of becoming infected at work. The complexity of networks, supply chains, and just-in-time inventories makes it possible for absenteeism in certain groups to trigger ripple effects that reach much further. Business continuity planning in critical industries, including cross-training of workers, may reduce this risk.
城市和国家之间的旅行可能会急剧减少，这不仅是因为可用于运营交通系统的工作人员减少，还因为想要或能够旅行的人越来越少。
Travel between cities and countries may be sharply reduced, not only due to fewer staff personnel available to operate the transportation system, but because fewer people will want to, or be able to, travel.
3.3.2 伤亡情况 Fatalities/Injuries —
健康影响的估算见表3-1和3-2。中度和重度大流行的影响估算是通过外推20世纪大流行的数据得出的（方法见附录3-B）。改进的医疗护理、抗病毒药物等干预措施，以及可能更广泛的疫苗供应，可能会将健康影响降低到低于所示水平。然而，新的亚型（如H5N1）可能导致比1918年更严重的感染。表3-1中的估算是单次大流行波次期间将发生的总事件。病例、住院和死亡将在大约三个月内发生，每个社区在此期间经历6到8周的疫情。衡量大流行对社区和医疗保健服务影响的更好指标是基于需要这些服务的人群比例，以及估计所需时间来评估的能力要求。
Estimates of health impact are provided in Tables 3-1 and 3-2. Estimates for the impact of moderate and severe pandemics are derived by extrapolating data from 20th century pandemics (see Appendix 3-B for methods). Improved medical care, interventions such as antiviral drugs, and possibly broader vaccine availability could reduce health impact below the levels shown. However, a new subtype (e.g., H5N1) could result in even more severe infection than 1918. Estimates in Table 3-1 are total episodes that would occur during a single pandemic wave. Cases, hospitalizations, and deaths would occur over about three months, with each community experiencing outbreaks for 6 to 8 weeks during this period. A better measure of the impact of a pandemic on community and health care services is based on the proportion of the population that will need those services and on the capacity to provide them over the estimated time needed.
| 特征 Characteristic | 中度（1958/68年类似） Moderate (1958/68-like) | 重度（1918年类似） Severe (1918-like) | ||
|---|---|---|---|---|
| 总计 Aggregate | 每千人 Per 1,000 | 总计 Aggregate | 每千人 Per 1,000 | |
| 疾病人数 Illness | 90 million (30%) | 299.8 | 90 million (30%) | 299.8 |
| 门诊医疗护理人数 Outpatient medical care | 45 million (50%) | 149.9 | 45 million (50%) | 149.9 |
| 住院人数 Hospitalization | 719,000 | 2.4 | 8,520,000 | 28.4 |
| ICU护理人数 ICU care | 107,850 | 0.36 | 1,278,000 | 4.26 |
| 机械通气需求 Mechanical ventilation | 53,925 | 0.18 | 639,000 | 2.13 |
| 死亡人数 Deaths | 209,000 | 0.7 | 1,903,000 | 6.3 |
表 3-1 与中度和重度大流行性流感情景相关的疾病发生、医疗保健需求和死亡人数。有关计算方法和假设见附录3-B。 Table 3-1. Number of episodes of illness, health care use, and death associated with moderate and severe pandemic influenza scenarios. See Appendix 3-B for approach to calculations and underlying assumptions.
| 医疗保健负担 Health care burden | 中度（1958/68年类似） Moderate (1958/68-like) | 重度（1918年类似） Severe (1918-like) | ||
|---|---|---|---|---|
| 总计 Aggregate | 每千人 Per 1,000 | 总计 Aggregate | 每千人 Per 1,000 | |
| 医院床位 Hospital beds | 154,594 | 0.516 | 1,710,531 | 5.70 |
| ICU床位 ICU beds | 39,772 | 0.133 | 440,066 | 1.47 |
| 机械通气需求 Mechanical ventilation | 19,886 | 0.066 | 220,033 | 0.73 |
| 死亡人数 Death | 39,710 | 0.132 | 361,570 | 1.21 |
表 3-2 大流行暴发的高峰周期间的总体医疗保健负担及每千人负担。计算方法和假设见附录3-B。总体负担表示如果所有社区同时经历疫情高峰期间所需的住院床位、ICU床位和呼吸机数量。每千人所需的住院床位和ICU床位数据可供社区用于估算其在大流行期间的医疗负担。 Table 3-2. Aggregate health care burden and burden per 1,000 population during the peak week of a pandemic outbreak. See Appendix 3-B for approach to calculations and underlying assumptions. Aggregate burdens represent the number of hospital beds, ICU beds, and ventilators needed if all communities simultaneously experience their epidemic peak. Hospital bed and ICU bed requirements per 1,000 population are provided for epidemiologic scaling at the community level.
通过使用美国疾病控制和预防中心（CDC）的Flu-Aid和Flu-Surge程序，可以针对几乎任何人口规模生成额外的情景和估算。这些免费软件程序旨在帮助州和地方公共卫生官员为下一次流感大流行进行规划、准备和演练。这些软件可以在http://www.hhs.gov/nvpo获取。
Additional scenarios/estimates can be generated for virtually any population level using the CDC’s Flu-Aid and Flu-Surge programs, which are free software programs designed to help State and local public health officials plan, prepare, and exercise for the next influenza pandemic. The software is available at http://www.hhs.gov/nvpo.
无法确切预测严重和致命感染的风险人群。然而，最有可能包括患有慢性疾病的人，如哮喘等呼吸系统疾病，心脏病和糖尿病，以及患有免疫功能受损疾病或接受相关治疗的人（例如癌症和获得性免疫缺陷综合症[AIDS]）。婴儿、孕妇和老年人也可能有高风险。在1918年大流行中，大多数死亡病例发生在年轻且先前健康的成年人中。这种模式在1957年或1968年的大流行中未出现。虽然在每年季节性流感疫情中，超过90%的死亡发生在65岁及以上的人群中，但在大流行期间，年龄分布可能会发生显著变化。
Risk groups for severe and fatal infections cannot be predicted with certainty. Most likely, they will include persons with chronic illnesses such as respiratory diseases including asthma, heart disease, and diabetes, and those with immunocompromising conditions or treatments (e.g., cancer and acquired immunodeficiency syndrome [AIDS]). Infants, pregnant women, and the elderly may also be at high risk. In the 1918 pandemic, most deaths occurred among young, previously healthy adults. This pattern did not occur in the 1957 or 1968 pandemics. Although over 90% of deaths occur annually in seasonal influenza in persons 65 years of age and older, the age distribution may shift significantly during a pandemic.
3.3.3 财产损失 Property Damage —
财产损失不太可能发生，除非因大流行性流感相关的缺勤引发与维护相关的故障和/或事故。 Property damage is unlikely, except to the extent that pandemic influenza-related absence from work may cause maintenance-related failures and/or accidents.
3.3.4 服务中断 Service Disruption —
在更严重的大流行中，一些服务中断可能会发生，特别是在社区疾病暴发的高峰周期间。在中度大流行中，中断可能较少，但系统和基础设施的复杂性使其在某些关键功能未能执行时容易受到影响。在任何规模的大流行中，医疗保健系统即使没有不堪重负，也会面临严重压力。 Some service disruption is likely in a more severe pandemic, particularly during the peak weeks of disease outbreaks in communities. Disruption may be minimal in a moderate pandemic, although the complexity of systems and infrastructures make them vulnerable to disruption if certain critical functions are not performed. In a pandemic of any magnitude, the health care system would be under severe stress, if not overwhelmed.
由于大量与流感相关的紧急呼叫和可用工人数量的减少，基本服务人员和急救人员的工作量也可能受到严重压力。同样，这种干扰的程度将取决于人们生病的模式、生病的时间以及他们的病情有多严重。 The workloads of essential service personnel and first responders are also likely to be severely strained, due to large numbers of influenza-related emergency calls and the decreased numbers of available workers. Again, the extent of such disruptions will depend on the pattern of which persons become ill, when they become ill, and how ill they become.
3.3.5 经济影响 Economic Impact —
对于中度大流行，在缺乏有效干预措施的情况下，与疾病相关的直接和间接成本（包括终生生产力损失成本）约为1810亿美元（以2004年美元估计）。此估算未包括因贸易和其他经济活动中断产生的成本。为了便于说明，如果经济活动在两波大流行高峰周内每波都减少了50%，假设美国国内生产总值（GDP）约为每年11.7万亿美元，那么总经济损失将为4500亿美元。经济破坏的实际程度及其持续时间尚不清楚，但将与大流行的严重程度有关。 For a moderate pandemic, the direct and indirect illness-associated costs, including lifetime lost productivity costs, in the absence of an effective intervention are about $181 billion (estimated in 2004 U.S. dollars). This estimate does not include costs associated with disruption of trade and other economic activities. To illustrate, if economic activity were reduced by 50% for each of two pandemic waves over the peak weeks, total economic loss would be $450 billion assuming a U.S. Gross Domestic Product (GDP) of approximately $11.7 trillion annually. The actual extent and duration of economic disruption are unknown and will be related to the severity of the pandemic.
3.3.6 长期健康问题 Long-Term Health Issues —
许多从严重流感相关疾病中康复的人在大流行结束后可能需要几个月的护理和康复。感染的长期后遗症并不常见。 Many people recovering from severe influenza-related illnesses may need care and convalescence for several months after the pandemic has ended. Long-term sequelae of infection are not common.
APPENDIX 3-A: Timeline of Events for the Influenza Pandemic of 1957-1958
| 时间 Time | 事件 Event |
|---|---|
| 1957年2月 February 1957 | 中国贵州省发生流感样疾病（ILI）疫情。 Outbreaks of ILI occur in Guizhou Province, China. |
| 3月初 Early March 1957 | 中国云南省发生ILI疫情。 Outbreaks of ILI occur in Yunan Province, China. |
| 3月中旬 Mid-March 1957 | ILI疫情在中国广泛传播。 Outbreaks of ILI are now widespread in China. |
| 4月 April 1957 | 香港、新加坡和台湾报告ILI疫情。 Outbreaks of ILI occur in Hong Kong, Singapore, and Taiwan. |
| 5月中旬 Mid-May 1957 | 在日本分离出与ILI相关的流感病毒。 Influenza virus associated with ILI is isolated in Japan. |
| 5月下旬 Late May 1957 | 美国6家制药公司开始生产疫苗。 Six pharmaceutical companies begin vaccine production in the United States. |
| 6月至7月 June-July 1957 | 在美国分离出该病毒；军事设施和其它封闭或”特殊”环境中报告流感疫情。 The virus is isolated in the United States; outbreaks of influenza are reported in military facilities and other closed or “unique” settings. |
| 8月中旬 Mid-August 1957 | 随着儿童返校，路易斯安那州出现首个大流行疾病的社区疫情。 The first community outbreaks of pandemic disease occur in Louisiana when children return to school. |
| 8月下旬 Late August 1957 | 400万剂单株大流行性流感疫苗投放市场。 Four million doses of pandemic influenza (single-strain) vaccine are released. |
| 9月 September 1957 | 流感在美国广泛传播。900万剂单株流感疫苗投放市场。 Widespread occurrence of influenza begins in the United States. Nine million doses of single-strain influenza vaccine are released. |
| 10月 October 1957 | 疾病的发病高峰出现。1700万剂单株疫苗投放市场。 The peak incidence of the disease occurs. Seventeen million doses of the single-strain vaccine are released. |
| 10月下旬 Late October 1957 | 流感疫苗需求下降。 The demand for influenza vaccine declines. |
| 11月 November 1957 | 新病例数下降。2200万剂疫苗投放市场。 The incidence of new cases declines. Twenty-two million doses of vaccine are released. |
| 12月初 Early December 1957 | 已累计投放6000万剂疫苗，但大部分疫苗未使用。 A cumulative total of 60 million doses of vaccine have been released, but much of the vaccine has gone unused. |
| 1958年1月至2月 January-February 1958 | 观察到肺炎和流感相关死亡人数的第二个高峰，老年人的死亡比例高于正常水平。 A second peak of pneumonia and influenza-related fatalities is observed, with a higher-than-usual proportion of fatalities among the elderly. |
APPENDIX 3-B: Methods for Calculating Pandemic Health and Health Care System Impacts
在中度和重度大流行中可能发生的发病、住院和死亡数字是根据20世纪大流行的推断来估算的。具体方法由Meltzer等人发表在1999年的《Emerging Infectious Diseases》杂志上。简而言之，作者从1957年和1968年大流行以及大流行后不久的几年中提取数据，确定按年龄类别和风险组划分的各种结果的发生率。数据被外推到当代美国年龄和风险分层的人口中。对15%至35%的发病率进行了影响估计。经济数据来自各种来源。使用关键输入变量采用预定义概率分布，通过多次模拟（蒙特卡洛方法，Monte Carlo）进行建模。
The numbers of episodes of illness, hospitalization, and death that may occur in moderate and severe pandemics are estimated based on extrapolation from 20th century pandemics. Methods are published by Meltzer et al in Emerging Infectious Diseases, 1999. In brief, the authors extracted data from the 1957 and 1968 pandemics and the immediate post-pandemic years to determine the rates of various outcomes by age category and risk group. The data were extrapolated to the contemporary U.S. age- and risk-stratified population. Impact estimates were developed for attack rates of 15% through 35%. Economic data were drawn from various sources. Modeling was done with multiple simulations (Monte Carlo methods) using predefined probability distributions for key input variables.
尽管Meltzer对15%到35%的大流行波峰中的疾病发病率进行了建模，但对20世纪大流行的发病率分析表明，每次大流行的发病率约为30%（选择作为中度和重度情景的估算基础）。不同大流行中，患病者的住院率和死亡率不同。此外，在1918年大流行期间，以前健康的年轻成年人有很高的死亡风险，而1957年或1968年没有出现这一死亡率高峰。这种差异反映在此处给出的中度和重度情景中。
Although Meltzer modeled illness attack rates in a pandemic wave ranging from 15% to 35%, analysis of rates of illness from 20th century pandemics indicates an attack rate of about 30% in each (chosen as the basis for estimates in the moderate and severe scenarios). Rates of hospitalization and death among those who become ill differ across pandemics. Additionally, in the 1918 pandemic, there was a high risk of death among previously healthy young adults, a mortality peak not seen in 1957 or 1968. This difference is reflected in the moderate and severe scenarios presented here.
将疾病发病和住院情况转换为医疗保健负担，需要估算住院时间（普通床位和ICU床位）、需要重症监护的比例，以及其中需要机械通气的比例。使用FluSurge软件进行建模（http://www.cdc.gov/flu/flusurge.htm）。模型中使用的假设包括：
Converting episodes of illness and hospitalization to estimates of health care burden requires estimating the duration of hospitalization (in normal and ICU beds), the proportion who require intensive care, and, among these, the proportion who require mechanical ventilation. Modeling was done using FluSurge software (http://www.cdc.gov/flu/flusurge.htm). The assumptions used in the model include:
- 流感住院时间：7天 Duration of hospital stay for influenza: 7 days
- ICU住院时间：10天 Duration of ICU stay: 10 days
- 机械通气持续时间：10天 Duration of mechanical ventilation: 10 days
- 需要ICU护理的住院患者比例：15% Proportion of hospitalized persons requiring ICU care: 15%
- 需要机械通气的ICU患者比例：50% Proportion of ICU patients requiring mechanical ventilation: 50%
- 社区内的大流行疫情持续时间：8周 Pandemic outbreak duration within a community: 8 weeks
使用这些参数，根据1918年大流行的数据校准社区流行病曲线的形状（由大流行疫情期间每天患病率的变化建模），表明疫情开始和高峰之间的死亡率相差约7倍。
Using these parameters, the shape of the epidemic curve in a community (modeled by the change in rates of illness per day during the pandemic outbreak) was calibrated to data from the 1918 pandemic, which indicated an approximate 7-fold difference in mortality rates between the beginning and peak of the outbreak.
医院床位容量和ICU床位容量的数据来自2003年美国医院协会医院年度调查报告。美国医院总床位的估计值考虑了未回复调查的情况。未对ICU床位进行推算；因此，ICU床位估算可能低于实际水平。根据美国预算管理办公室（U.S. Office of Management and Budget）的大都市统计区域划分，对城市地区和农村地区的数据进行分层。
Data on hospital bed capacity and ICU bed capacity was obtained from the 2003 American Hospital Association Annual Survey of Hospitals. Estimates of total hospital beds in the United States take into account non-response. Extrapolations are not done for ICU beds; thus, these likely represent an underestimate of ICU bed capacity. Data are stratified for urban and rural areas according to the U.S. Office of Management and Budget’s metropolitan statistical area designations.