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[Lancet发表文章]:上海应对当前新冠奥密克戎疫情:拯救生命的努力
2022年05月12日 研究点评, 进展交流 暂无评论

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Shanghai's life-saving efforts against the current omicron wave of the COVID-19 pandemic

Xinxin Zhang, Wenhong Zhang, Saijuan Chen

Lancet Published:May 06, 2022

DOI: https://doi.org/10.1016/S0140-6736(22)00838-8

In late February, 2022, a wave of SARS-CoV-2 infection rapidly appeared in Shanghai, China. According to the Shanghai Municipal Health Commission, as of May 4, 2022, 601 942 cases have been identified, including 547 056 asymptomatic carriers. 503 people have died with or from COVID-19. Phylogenetic features of SARS-CoV-2 viral genomes from 129 patients in this period, and inferring their relationship with those available on the GISAID database, indicated that all of the new viral genomes in Shanghai were clustered into the SARS-CoV-2 BA.2.2 sub-lineage. Of note, BA.2 is a sub-lineage of the omicron variant of SARS-CoV-2 (B.1.1.159). Multiple sub-lineages of BA.2 have been characterised, many of which appear to show distinct regional distribution patterns. At present, BA2.2 only represents a small sub-lineage of BA.2 worldwide (1993 [0·25%] of 800 366 seqences in GISAID), sequences of which have been detected in Hong Kong (839 [42·10%]), the UK (742 [37·20%]), and Australia (121 [6·10%]). We assessed the potential risk of various feature mutations on BA2.2 on the severity of COVID-19 and found that these mutations showed no significance in their distributions between severe to critical and mild to moderate COVID-19, suggesting that the observed disease severity is probably mainly attributed to comorbidities.

Although omicron BA.2 evolves towards less virulent, a higher rate of severe outcomes and considerable mortality have been reported in unvaccinated people, especially older adults.1 This has been confirmed in Hong Kong, where health authorities have reported 9115 deaths among 1 192 765 people with SARS-CoV-2 (crude case fatality rate 0·76%) during the fifth wave of the pandemic, as of May 4, 2022.2 The crude case fatality rate in those older than 60 years (19·30% of this age group has not been vaccinated) was 2·70%. Comparatively, only 2% of New Zealand's population older than 60 years has not been vaccinated, which is highly correlated with a low COVID-19 crude case fatality rate of 0·07%.

In Shanghai, with a population of 25 million, the overall vaccination coverage now exceeds 90%; however, vaccination coverage has remained low in older adults—62% of 5·8 million people older than 60 years have been vaccinated, and only 38% have received a booster vaccination. As of May 4, 2022, among the 503 people who died with or from COVID-19, only 25 patients had received at least one dose of COVID-19 vaccine. The vaccination rate for the deceased patients was only 4·97%. If no strict public health measures were taken, such as large scale viral nucleic acid and antigen screening, quarantine of infected cases and close contacts in shelter hospitals and hotels, respectively, and lockdown of districts with severe outbreak, the number of severe to critical cases and the resultant death toll could be high among the older people without vaccination. The strict and comprehensive pandemic control strategies in Shanghai are therefore actually to reduce the number of people infected and to provide early diagnosis and appropriate treatment for severe COVID-19 so that the case fatality rate can be minimised, and to buy time for full vaccination coverage.

Local citizens have suffered in their daily lives from inconveniences of lockdown. Some people even developed mental health symptoms as a reaction to the unexpected crisis. Facing these challenges, social workers and many volunteers have made great contributions to the care of the people in need from both material and psychological perspectives. The food and daily consumable supply are ensured thanks to the support of many other cities and provinces. Through the unprecedented efforts of health professionals in Shanghai and those coming from other cities, and of people from all the circles in Shanghai, the strategies have shown very promising results, as indicated by an R0 of 9·5 at the beginning of the wave to an Rt of 0·67 on May 1, 2022.3 The number of newly infected cases, after peaking at 27 719 on April 13, 2022, has now dropped to 4651 cases, as of May 4, 2022.

Life-saving efforts are continuing with the improvement of public health measures and social services on one hand, and treatment of hundreds of severe to critical cases on the other. Meanwhile, the return to normal life and work is proceeding in a stepwise manner, and people in Shanghai is hailing the light at the end of the tunnel.

Shanghai's great efforts against omicron are essential for China to exit from the pandemic in a larger sense. As a leading economic centre and an open city in China, Shanghai has huge exchanges with other cities and regions in the country, so the spill-out of virus to other places, especially in the central and western regions with insufficient medical resources and lower vaccination coverage, could have unimaginably severe consequences. In this regard, strict control strategies in Shanghai might have prevented the continuous spread and a large number of deaths. According to the Chinese National Health Commission,4 about 49 million people older than 60 years have not yet been vaccinated, and among this population, a considerable number suffer from underlying diseases. The persistence of dynamic zero COVID-19 community transmission in Shanghai and other cities will overcome weak links in the immunological barrier in populations across the country. Fortunately, besides the available vaccines and heterologous vaccination approach, several new vaccines specifically targeting omicron variants, including mRNA vaccine, inactivated vaccine, and recombinant Spike protein subunit vaccine, have also been approved for clinical trials in China and could soon be available for emergency use. The next challenge will be to enhance the communication between the health-care providers and the public to overcome the vaccine hesitancy and make the vaccination service accessible to all people, the older and vulnerable people in particular. Moreover, the production of effective anti-SARS-CoV-2 drugs and preparation of sufficient medical resources, including intensive care units and teams for severe diseases and training of grassroots-level health-care workers capable of last-mile services of disease control and prevention are on the way. We believe that China will win the fight against the COVID-19 pandemic in joint efforts with other members of the international community in the not too distant future.

2022年2月下旬,上海出现了一轮本土新冠病毒感染疫情。据上海市卫健委通报,截至2022年5月4日,上海市累计有601,942例新冠病毒感染者,其中547,056例为无症状感染者,累计死亡503例。对来自本轮疫情期间129名患者的新冠病毒基因组系统进化特征与全球流感共享数据库(GISAID)中的数据相互关系进行比较,显示上海地区新发感染的病毒基因组都属于新冠病毒BA.2.2亚系。值得注意的是,BA.2是新冠病毒奥密克戎变异株(B.1.1.159)的一个亚株。BA.2已发现有多个亚系,且这些亚系显示出不同的地域分布模式。目前,BA2.2仅代表全球BA.2的一个小亚系(在GISAID数据库的800,366 条序列中有1,993条[占0.25%]),该亚系的病毒序列已在香港地区(839条[占42.10%])、英国(742条[占37.20%])和澳大利亚(121条[占6.10%])被检测到。我们评估了BA2.2亚系各种突变对新冠严重程度的潜在风险,没有发现这些突变在重症与轻症病例间的分布存在显著差异,提示在临床上观察到的疾病严重程度可能主要归因于患者的合并症。

尽管奥密克戎BA.2亚系的毒性较弱,但据报道,未接种疫苗的人,尤其是老年人[1],在感染后进展为重症病例或出现死亡的可能性仍较高,这已在香港地区的疫情中得到证实。香港卫生署报告称,截至2022年5月4日,第五波疫情期间1,192,765名新冠病例中有9,115例死亡(粗病死率为0.76%)[2],而60岁以上人群(该年龄段约19.30%的人未接种疫苗)的粗病死率则为2.70%。相比之下,新西兰60岁以上人群中只有2%没有接种疫苗,这与其低至0.07%的新冠疫情粗病死率呈高度相关。

上海拥有2,500万人口,总体疫苗接种覆盖率已超过90%;然而,老年人的疫苗接种覆盖率仍然较低——在580万60岁以上的人群中,接种疫苗的比例为62%,而只有38%接种了疫苗加强针。截至2022年5月4日,在503例新冠死亡病例中,只有25名患者接种了至少一剂新冠疫苗。死亡患者的疫苗接种率仅为4.97%。如果不采取严格的公共卫生措施,包括大规模病毒核酸检测和抗原筛查,在方舱医院和隔离酒店分别隔离感染病例和密切接触者,以及对疫情严重地区实行封控,那么在没有接种疫苗的老年人中的重症病例和死亡人数可能会很高。因此,上海对疫情严格而全面的控制策略实际上是为了减少感染人数,为重症新冠病例提供早期诊断和充分治疗,从而将病死率降至最低,并为疫苗的全面接种赢得时间。

上海的封控给当地居民的日常生活带来了不便,一些市民在意外危机下出现了心理压力。面对这些挑战,社会工作者和许多志愿者为有需要的居民从物质到心理层面都提供了帮助,做出了巨大贡献。受益于许多省市的支持,上海市民的食品和日用消费品供应得到了基本保障。经过上海本地和其他城市援沪医卫工作者以及上海各界人士的空前努力,抗疫策略已经显示出可观的效果,基本再生指数已由疫情开始时的9.5降至2022年5月1日的0.67[3]。新增感染病例数在2022年4月13日达到峰值的27,719例后开始逐步下降,截至2022年5月4日已降至4,651例。

上海拯救生命的努力仍在继续。一方面公共卫生措施和社会服务在持续改善,另一方面正对数百名重症、危重症病例进行救治。与此同时,恢复正常生活秩序和复工复产正在逐步推进,上海人民正在迎接走出此轮疫情的曙光。

上海抗击奥密克戎疫情的巨大努力对于中国在更大范围内走出此轮疫情至关重要。上海作为中国领先的经济中心和开放城市,与全国其他城市和地区有着巨大的人员交流。若任由病毒外溢,尤其是扩散到医疗资源不足、疫苗接种率不够的中西部地区,则会产生难以想象的严重后果。在这方面,上海的严控策略阻止了疫情的持续传播和潜在的大量人员死亡。根据中国国家卫生健康委员会的数据[4],中国大约有4,900万60岁以上的老人尚未接种疫苗,其中相当一部分人患有基础疾病。上海和其他城市坚持动态清零政策将有助于度过目前全国人口免疫屏障尚薄弱的短暂阶段。幸运的是,除了现有的疫苗和异源疫苗接种策略外,一些专门针对奥密克戎变异株的新疫苗,包括mRNA疫苗、灭活疫苗、重组蛋白亚单位疫苗等也已获批在中国进行临床试验,并将很快可供应急使用。下一个挑战将是如何加强卫生工作者和公众的沟通,使民众克服对疫苗的“疫苗犹豫”(vaccine hesitancy),让所有人、特别是老年人和脆弱人群都能获得疫苗接种服务。此外,生产有效的抗新冠病毒药物,充实包括重症监护室和重症监护团队的医疗资源,培训能够为疾病防控提供最后一公里服务的基层医务人员等工作,都在推进之中。我们相信,中国将与国际社会其他成员共同努力,在不久的将来赢得防控新冠疫情的胜利。

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