General office of the national health and family planning commission concerning the diagnosis and treatment schemes (2016 edition) yellow fever

The 2016-04-05 national health and population and family planning commission of the People's Republic of China

Countries who do medical letter [2016] no. 323

Provinces, autonomous regions and municipalities directly under the central government health and family planning commission, the xinjiang production and construction corps health bureau:

Yellow fever is mainly popular in the tropical regions of South America and Africa. Was confirmed on March 12, 2016, the first in our country imported cases of yellow fever, as of March 24 JCP found imported cases, 6 cases were from Angola. To do a good job in medical treatment related to yellow fever by experts in the relevant reference to the world health organization guidelines and summarizing the relevant domestic cases of medical experience, on the basis of revising perfect scheme of yellow fever diagnosis and treatment, forming the yellow fever diagnosis and treatment schemes (2016 edition) (can be downloaded from the national health and family planning commission web site). Hereby printed and distributed to you, please refer to execution.

Around the family planning administrative department of public health, especially with the outbreak occurred port district family planning department of public health personnel exchanges, to continue to make preparations for the relevant prevention and control and medical treatment, keep communication with port health quarantine and transportation departments and linkage, ensure the prevention and control measures put in place. Must strengthen the case management, accomplish early discovery, early diagnosis, early treatment, in accordance with the relevant therapeutic regimen for patients with standard medical services, to do a good job of anti-mosquito isolated cases. Strengthen medical personnel training, improve the ability of yellow fever early recognition and diagnosis and treatment. With the spread of disease distribution of mosquito-borne province should strengthen environmental health regulation, according to the situation of mosquito-borne monitoring work timely and effective to carry out the mosquito, reduce the risk of mosquito-borne diseases spread.

Touch: medical hospital authority resources Qing-hua luo, leah, rui-rong hu

Contact phone: 010-68791875, 68791885, 68791887

The true: 010-69792963

E-mail: bmaylzyc@163.com

General office of national health and family planning commission

On March 30, 2016

Yellow fever diagnosis and treatment plan

(2016)

Yellow fever (Yellow fever) is a kind of caused by Yellow fever virus, the acute infectious disease transmission by mosquito bites. Clinical manifestations are mainly fever, jaundice, bleeding, etc. Mainly in the tropical regions of South America and Africa. The world health organization estimates that 2013 African for yellow fever caused severe cases for example, 84000-170000 of 29000-60000 cases died. Angola in 2015 confirmed the first cases on December 5, 2016 - March 20 JCP report suspected cases of 1132 cases, 375 cases of confirmed 168 cases of death. Was confirmed on March 12, 2016, the first in our country imported cases of yellow fever, ending March 2016 JCP found 24 imported cases, 6 cases from Angola.

A, etiology,

Yellow fever virus (Yellow fever virus get) for single strand RNA virus is chain, belong to the Yellow virus (Flaviviridae) Yellow virus genera (Flavivirus). Virus particles are spherical, 40-60 nm in diameter, outer lipid membrane, the surface have a spine, the length of the genome of about 11 KB.

Yellow fever virus is only one serotype, according to the prM, E and 3 utr nucleotide sequence is divided into multiple genotypes.

Yellow fever virus resistance is weak, no acid, no heat. 60 ℃ for 30 minutes can be inactivated, 70% ethanol, 0.5% sodium hypochlorite, disinfectants, such as grease solvent, peracetic acid and ultraviolet irradiation can be inactivated.

Yellow fever virus with yellow virus families and other members, such as dengue virus, west Nile virus, st. Louis encephalitis virus, such as village card virus produce cross serological reaction.

Second, the pathogenesis and pathological changes.

(a) pathogenesis.

The pathogenesis of yellow fever is unclear. Virus may be passed on the bite site copy, lymph and blood spread to other organs and tissues, and constantly develop in it, and then released into the blood, and cause viremia, mainly into the liver, spleen, heart, bone marrow and striated muscle, etc.

Target organ damage may be virus caused by direct action. The liver is the main target organ, the patient with liver damage and elevated serum transaminase, bilirubin and thrombin time extended, etc.. at the same time visible kidney, heart, etc. TNF of liver and spleen macrophages to produce cytokines, such as oxygen free radicals accumulation, endothelial cell injury, micro thrombosis and disseminated intravascular coagulation (DIC), is the possible cause of the multiple organ damage and shock. Bleeding may be due to thrombocytopenia, vitamin K - rely on blood coagulation factors in the liver synthesis to reduce and diffuse intravascular coagulation (DIC), and other causes.

(2) the pathological changes.

The disease can cause extensive tissue pathological changes, including the liver pathological changes has specificity.

Liver enlargement, lobular central parenchyma cell necrosis, cloudy swelling of liver cells, nuclei, assume the multiple small vacuoles sex adipose change, coagulation necrosis and acidophilic hyaline degeneration, serious when can happen the lobular necrosis, but no obvious inflammation and hyperplasia of fibrous tissue, mesh structure collapse.

Acute renal enlargement, renal tubular necrosis (see more at proximal convoluted tubules), renal tubular epithelial steatosis, fall off or necrosis, tube cavity full of detrital grain appearance. Glomerular damage, special staining found basement membrane Schiff staining positive, in the proximal convoluted tubule and bowman's capsule cavity inside the protein sample material deposition.

Myocardial steatosis, turbidity swelling and degeneration.

Spleen congestion, lymphocytes in spleen and lymph nodes significantly reduced, instead of mononuclear cells and tissue cells.

Brain tissue can have small focal hemorrhage and edema, and no obvious inflammatory cells infiltration.

In addition, fair skin, gastrointestinal mucosa bleeding, XiongFuQiang a small amount of effusion.

Three, epidemiology.

(a) infection.

According to the mode of transmission, yellow fever is mainly divided into urban and jungle. City's main source of infection for patients and the recessive infection, especially in patients within 5 days of stroke onset, with \"people - aedes aegypti -\" cycle. The main source for the spread of jungle monkeys and other nonhuman primates, as \"monkey - African aedes mosquitoes or hasten blood mosquito - such as a monkey\" way of circulation, the person infected by into the jungle were mosquito bites.

Mosquito bites of infected people and nonhuman primates, by 8 to 12 days can be contagious. The infected mosquitoes can be a lifelong carry virus, and can the egg batches.

(2) the route of transmission.

The main transmission by mosquito bites. Urban yellow fever media mainly aedes aegypti. Jungle of vector mosquitoes are complex, including Africa aedes mosquitoes, Simpson aedes mosquitoes, blood mosquito genus, evil spirit are, etc.

(3) the population susceptibility.

Yellow fever virus generally susceptible. Infection or vaccination can obtain lasting immunity.

(4) popular characteristics.

1. Distribution: mainly in tropical Africa and central and South America.

2. Seasonal distribution: in endemic areas throughout the year all can come on, mosquito-borne active peak season.

Four, clinical manifestation

The incubation period is usually 3 to 6 days, also can be up to 10 days.

Most people are infected with yellow fever virus after asymptomatic or mild infection. Typical cases of clinical course can be divided into the following four periods.

(a) infection period.

This period is the viremia stage, for 3 to 5 days.

Acute onset, chills, fever (up to 39 ℃ - 41 ℃), the whole body discomfort, headache, photophobia, lumbar di ministry and lower limb pain (especially the knee), muscle pain, anorexia, nausea, vomiting, restlessness, irritability, dizziness, etc., but no specific symptoms.

Physical examination can be relatively slow pulse, the skin, conjunctiva and gum hyperaemia, tongue coating change characteristic (tongue edge sharp red with white moss), liver and epigastric tenderness.

(2) remission.

Onset of 3 to 5 days later, the patient into remission, hypothermia, relieve symptoms. Most of the patients started to recover, but about 15% of patients within 48 hours the illness is aggravating, again into the third phase (poisoning).

Stage (3) poisoning (liver and kidney damage).

This period is characterized by the illness is aggravating, again appear multiple organ damage, often involving the liver, kidney and blood system, etc. Clinical manifestations of elevated temperature again, jaundice gradually aggravate, frequent vomiting, abdominal pain, can appear more bleeding, such as skin bruises, petechiae, epistaxis, mucosal bleeding, even tract bleeding, shock. Abnormal renal function, proteinuria, hematuria, reduced the volume of urine, even anuresis. Abnormal ecg visible ST -t, few can appear acute heart. Nervous system characterized by agitation, delirium, coma, cerebrospinal fluid examination stress increased obviously, higher protein but not interleukin increased significantly. About 50% patients with stage into the poisoning of death.

(4) recovery.

Recovery sustainable 2-4 weeks. Temperature dropped to normal, the symptoms gradually disappear, organ function gradually returned to normal. But fatigue symptoms last for several weeks. Jaundice and sustainable transaminase eleations for months. Death reported patients in convalescence and many died of cardiac arrhythmias.

Five, the laboratory examination

(a) general inspection.

Routine blood, peripheral blood leukocyte reduction, neutrophils ratio decreased, the platelet decline.

Routine urine, proteinuria, and particle shape and red blood cells.

The stool test: defecate occult blood test can be positive.

Biochemical examination: elevated serum transaminase earlier than bilirubin, nmda aminotransferase (AST) higher level higher than that of alanine transaminase (ALT), can reach more than 20000 U/L. Also can obviously increase the serum bilirubin, up to 255-340 (including mol/L. Also visible blood ammonia increase, reduce blood sugar, etc.

Blood coagulation function, prothrombin time, prothrombin activity decreased, blood coagulation factors (II, V, VII, IX and X). Some cases of diffuse intravascular coagulation (DIC) corresponding coagulant function abnormality.

Renal function examination: serum creatinine levels.

Myocardial injury markers check: myocardial damage with elevated blood troponin is obvious.

Other biochemical inspection: myoglobin, blood amylase, lipase, urine amylase can be significantly increased.

(2) serologic test.

Serum specific IgM antibody: 1. By adopting the method of ELISA, immunofluorescence test, capture the result of the method of detecting IgM antibody is more reliable. Generally 5 to 7 days after the onset IgM antibody, could be sustainable for several years.

2. The serum levels of specific IgG antibody by ELISA, immunofluorescence antibody assay (IFA), such as immune chromatography methods.

Yellow fever virus antibodies and other yellow virus of the genus dengue virus, village card virus and antibody of west Nile virus has strong cross reaction, prone to false positives, identification should be paid attention to at the time of diagnosis.

(3) the etiology examination.

1. Detection of nucleic acids: nucleic acid amplification technologies such as application of rt-pcr test specimens of blood, urine and other body fluids, yellow fever virus RNA can be used for early diagnosis of disease.

2. Virus isolation: within 5 days after onset patients deaths from blood or tissue samples can be used for virus isolation. Newborn milk available within the mouse vaccination or Vero cells and C6/36 sensitive cells, such as virus in BSL - three lab-grown separation.

3. The antigen detection: using immunohistochemical method to detect virus antigen in tissue samples; By adopting the method of ELISA detection virus antigen in blood and other specimens.

Sixth, the diagnosis and differential diagnosis

(a) diagnosis basis.

According to the history of epidemiology, clinical manifestation and related laboratory synthetic judgment.

(2) the case definition.

1. The suspected cases: conform to the history of epidemiology and clinical manifestations of accordingly.

(1) the history of epidemiology: in 14 days before the onset of living in the endemic areas or travel history.

(2) clinical manifestations: hard to explain with other causes of fever, jaundice, liver and kidney impairment, or hemorrhage, etc.

2. Clinical diagnosis cases, suspected cases and yellow fever virus IgM antibody testing positive.

3 confirmed cases, suspected cases or clinical diagnosis cases through laboratory testing in accordance with one of the following circumstances:

(1) the yellow fever virus nucleic acid testing positive.

(2) yellow fever virus was isolated.

(3) recovery of yellow fever virus serum antibody degrees in the acute phase is more than 4 times and, at the same time out of dengue fever, village and other common yellow card virus infection.

(3) of the differential diagnosis.

Early or light cases with flu, typhoid fever, typhus and lassa fever and other identification; Fever with jaundice should be with a variety of causes of the liver damage, leptospirosis and identification; Fever associated with bleeding with hemorrhagic fever of renal syndrome and other viral haemorrhagic fever, dengue fever, tick-borne relapsing fever, falciparum malaria, etc.

The disease can occur with malaria, dengue fever at the same time.

Seven, treatment,

The disease without antiviral drug treatment, the main support symptomatic treatment.

(a) general treatment.

Acute period the patient should stay in bed and take effective anti-mosquito isolation measures. Closely observe the illness change, monitoring of vital signs. There are frequent vomiting, gastrointestinal bleeding should be fasting, intravenous hydration, maintain water, electrolyte and acid-base balance.

(2) of symptomatic and supportive treatment.

With a high temperature to physical cooling, if necessary, to the small dose of antipyretic analgesics, such as acetaminophen, adult usage for 250-500 mg/time, 3 to 4 times daily, children's usage for 10 to 15 mg/kg/times, between 4 to 6 hours, no more than 4 times in 24 hours. Disable aspirin.

Liver function damage, protect liver, reducing enzyme, retreat yellow treatment, vitamin K promote the synthesis of clotting factors, severe bleeding when added, platelets, fresh plasma clotting factors and transfusion of red blood cells when necessary.

Acute kidney injury, when necessary to renal replacement therapy.

When upper gastrointestinal bleeding in proton pump inhibitors and thrombin treatment.

Brain edema, to osmotic diuretic (3% hypertonic saline or 20% mannitol) dewatering treatment.

(3) the treatment of traditional Chinese medicine.

1. The choice of oral Chinese medicine syndrome differentiation medicinal broth.

(1) hot and humid YuZu certificate (see more at infection period)

Clinical symptoms: fever, bad cold, head, body pain, joints pain, photophobia, anorexia, ou, evil, restlessness, irritability, yellow urine, etc. Red tongue tip, whitish thick, greasy, pulse delay or speech &drama float number.

Treatment: clear heat, wet, through table muscle.

Reference: the formulas dew disinfection Dan muscle chai ge dissociation and tonga. Wormwood, radix scutellariae radix puerariae, honeysuckle, forsythia, bupleurum, Sue terriers, ageratum, talc, licorice, etc.

(2) the poison one gas camp certificate (see more at early poisoning)

Clinical manifestation: strong heat again, the sweat out hot, god faint, delirious speech. Eye yellow, yellow urine, urine. Skin spots, rash, polydipsia, vomiting, abdominal pain. Red tongue, white or yellow moss, pulse and moist or number.

Fresh air treatment: cool camp, purging fire detoxification.

Reference: the formulas antipyretic disease and add and subtract. Plaster stone, radix scutellariae, radix rehmanniae, fructus forsythiae and radix arnebiae seu lithospermi, gardenia, artemisinin, cortex moutan, buffalo horn, glabrous greenbrier rhizome, liquorice, etc.

(3) blood stasis poison into the fact (see more at poisoning)

On the clinical manifestations: strong heat, abdominal pain, jaundice, visible manic interference disturbing or god faint not awake, skin ecchymosis, vomiting blood, non-traumatic blood, stool or and see other fact, oliguria, dark red tongue, moss thin or greasy, less jin, pulse count.

Treatment: cold blood hemostasis, blood detoxification.

When reference drugs: horn to add and subtract. Buffalo horn, gardenia, radix rehmanniae, radix paeoniae rubra, cortex moutan, big field thistle, cogongrass rhizome, arborvitae, purple beads grass charcoal, garden burnet, sophora japonica, herba agrimoniae, etc.

(4) the sun be the spirit and anxiety syndrome (mostly in shock)

Clinical manifestations: body heat, pale face, and shortness of breath, sweating, limbs cold, faint delirious speech agitated or god, skin maculae or see all kinds of bleeding. Tongue reddish, micro pulse.

Treatment: Yang back to save the inverse, yiqi solid.

Reference: the formulas pulse dispersion and four inverse tonga subtraction. Red ginseng (Fried) against another, dwarf lilyturf, schisandra fruit, ripe aconite root, dried ginger, cinnamon, etc.

More than (5) evil not net card (recovery)

Clinical manifestation: listless, but, to drink, urine yellow light gradually. Pale tongue, little moss thick jin or less moss, pulse fine, number.

Treatment: clear heat, qi and nourishing Yin.

Reference: the formulas wormwood Chen Wuling powder. Wormwood, tuckahoe, alisma, atractylodes, caulis dendrobii, radix ophiopogonis, etc.

2. Choose proprietary Chinese medicine injection or intravenous drip Chinese medicine syndrome differentiation.

Choice of heat-clearing and detoxifying, cooling blood to remove stasis and replenishing qi, awake brain begin to understand the class preparation.

Eight, discharge standard

Comprehensive evaluation of hospitalized patients outcome situation to determine the discharge time. Suggestions in discharge shall meet the following conditions:

1. The temperature is normal, the clinical symptoms.

2. Blood nucleic acid detection 2 consecutive negative (more than 24 hours); Do not have the nucleic acid testing conditions, duration of not less than 10 days.

Nine, prevention,

(a) control the source of infection.

For suspected, cases of the clinical diagnosis and effective anti-mosquito isolation measures should be taken. From yellow fever epidemic area personnel to implement the health and quarantine.

(2) to cut off the route of transmission.

Anti-mosquito mosquito is an important part in the disease prevention and control measures.

(3) the protection of vulnerable groups.

In the endemic area personnel should be in at least ten days before departure to be vaccinated against yellow fever, personal anti-mosquito measures at the same time.