传染病学总论.ppt

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1、传染病学总论Introduction of communicable diseases,附属第一医院 感染科传染病诊治国家重点实验室,阮 冰,学习意义及重要性,掌握传染病的基本理论，基本概念，基本方法熟悉传染性疾病发生与发展规律认识突发或新发传染病,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,传染病历史回顾 古老的疾病,公元前3700年，古埃及雕像上患脊髓灰质炎下肢麻痹的牧师,公元前1196年，古埃及木乃伊脸面上的脓泡性病灶,三千多年前，我国甲骨文中记载的“虫”“蛊”“

2、疟疾”等疾病,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,plague, smallpox, cholera, influenza, malaria, schistosomiasis, kala-azar,传染病的暴发流行 瘟疫 pestilence,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,近百年流感流行状况,1918年流感大流行期间的医院急

3、诊室,流感大流行具有周期性,1957年亚洲暴发大规模流感,1969年香港流感暴发,1918-1919 西班牙流感 病毒类型 H1N1，通过参战的士兵传遍世界，大约4000万人死亡 1957-1958 亚洲流感 病毒类型 H2N2，死亡人数约200万 1968-1969 香港流感 病毒类型 H3N2，死亡人数约3.4万1977-1978 俄罗斯流感病毒类型H1N1 2009年甲型H1N1流感病毒类型新型H1N1，206个国家/地区出现实验室确诊病例，确诊病例53万多例，死亡6260例,传染病只能控制，不可能彻底消灭传染病的暴发与人类侵犯自然相关忽略对传染病的防控将带来新、老疾病的流行历史常常重演

4、，使传染病的格局不断发生变化,传染病暴发的历史带给我们的启迪,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,1. 微生物的发现,传染病防治的辉煌战果,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,人感染H7N9病毒的溯源,人感染H7N9病毒与活禽市场鸡分离的病毒高度同源（同源性超过99.4%），活禽市场是人类感染H7N9的主要源头H7N9病毒复制系统

5、重要基因出现突变，如PB2 Asp701Asn，更容易感染哺乳动物H7N9重症患者有类似SARS病毒感染的细胞因子风暴，而轻症患者无此现象,LANCET，April, 2013,2. 免疫学的兴起,消灭或基本控制 smallpox, poliomyelitis,传染病防治的辉煌战果,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,3. 抗微生物药物的发现和应用,传染病防治的辉煌战果,传染病诊治国家重点实验室 State Key Laboratory for Diagnosi

6、s and Treatment of Infectious Diseases,传染病防治的辉煌战果,4. 感染病学理论的形成,1884 “Koch法则”证病律,特殊的病原菌应在同一种疾病中查见，在健康者中不存在该特殊病原菌能被分离培养得到纯种该培养物接种至易感动物，能产生同样病症自人工感染的实验动物体内能重新获得该病原菌的纯培养,1854“Snow调查”流行病学的开端,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,Robert Koch,人类对传染病的认识是一个不断发展深

7、化的、漫长而复杂的过程，与自然科学的发展密切相关科学家在面对残酷严峻的疫情时，要怀有神圣的使命感和高度的责任心意外发现有时是点燃科学灵感的火花用科学的方法来研究问题，才能最终找到疾病流行的原因以及控制流行的措施尽早明确病原体及疾病流行的原因是最终控制感染病流行的关键预防与治疗同样重要，接种疫苗是预防传染病最根本的方法,辉煌战果带给我们的启迪,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,法定传染病尚未得到完全控制 viral hepatitis, HFRS, infect

8、ious diarrhea zoonoses (foot and mouth disease, plague, anthrax, rabies, tuberculosis) 已基本消灭的传染病再现 (re-emerging) TB, schistosomiasis, cholera, syphilis, measles,“再现传染病”不断流行,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,被认为非传染病但发现病原体 Helicobacter pyloyi早已存在但发现病原

9、体 hepatitis C/E, lyme disease, legionellosis新出现 AIDS, SARS, human avian influenza, resistant mutants,“新发传染病”输入及发现,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,生物恐怖 bioterrorism 病原体可被用作生物武器 anthrax, plague, smallpox, Ebola,“生物恐怖”的警示,传染病诊治国家重点实验室 State Key Labor

10、atory for Diagnosis and Treatment of Infectious Diseases,对新发/特发传染病形成原因的思考,1. 微生物进化和变异,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,对新发/特发传染病形成原因的思考,2. 社会、环境因素,全球人口的增长和城市化进程加快人类社会行为的改变气候及生态环境的改变免疫虚损人群的增多抗生素和杀虫剂的广泛应用烈性微生物的散布,治理上述现象还有相当困难，消灭传染病任重道远,传染病诊治国家重点实验室 S

11、tate Key Laboratory for Diagnosis and Treatment of Infectious Diseases,Characteristics,Diagnosis,Treatment,Prevention,Communicable diseases,Infection & immunity,Epidemic process,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,概 念,感染性疾病 infectious diseases 传染病 com

12、municable diseases,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,第一节 感染与免疫,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,感染的概念,感染：病原体与人体的相互作用 感染病：感染后的临床或亚临床表现 机会性感染 opportunistic infection 条件致病菌 conditional (E. coli, Pseud

13、omonas, Fungi) 共生状态 commensalism,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,感染过程的表现,清除病原体 pathogen is eliminated or eradicated隐性感染 covert infection显性感染 overt infection 病原携带状态 carrier state 潜伏性感染 latent infection,传染病诊治国家重点实验室 State Key Laboratory for Diagnosi

14、s and Treatment of Infectious Diseases,(1) 清除病原体,非特异性防御能力 non-specific immunity 特异性免疫功能 specific immunity 主动免疫 active immunity 被动免疫 passive immunity,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(2) 隐性感染,病原体仅诱导机体产生特异性免疫应答，不引起或只引起轻微的组织损伤，在临床上不显出任何症状、体征，甚至生化改变，只能

15、通过免疫学检查才能发现 Pathogens only make the host producing specific immune response, not having histomorphological damage, no symptoms and signs, no any biochemical changes, only discovered by immunological examinations病原体通常被清除，但少数人可转变为病原携带状态 Pathogens can be eradicated or carried,传染病诊治国家重点实验室 State Key Lab

16、oratory for Diagnosis and Treatment of Infectious Diseases,(3) 显性感染,病原体侵入人体后，不但诱发免疫应答，而且通过病原体本身或机体的变态反应，导致组织损伤，引起病理改变和临床表现 Pathogens make the host producing specific immune response, having pathological changes显性感染过程结束后，有些传染病可使感染者获得较为稳固的免疫力，另一些传染病免疫力并不牢固 Immunity can be consolidated or temporary,传染病

17、诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(4) 病原携带状态,病原体侵入人体后，人体不出现任何的疾病状态，但能携带并排除病原体，成为传染病流行的传染源 No clinical manifestation but microorganism excreted分类： 按病原体： virus carrier, bacteria carrier 按发生和持续时间：convalescent, healthy or incubatory carrier 按携带病原体的持续时间： ac

18、ute or chronic carrier,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(5) 潜伏性感染,病原体感染人体后，机体免疫功能足以将病原体局限化但又不足以将病原体清除，病原体长期潜伏起来，待机体免疫功能下降时引起显性感染 Locates the pathogen but can not wipes it out, can latently for a long time, can occurs overt infection潜伏性感染与病原携带状态的区别？

19、What is the different point between latent infection and carrier state ?,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,潜伏感染显性感染病原携带状态 隐性感染 清除病原体,感染谱频度,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,感染过程中病原体的作用,侵袭力 invasiven

20、ess 毒力 virulence 数量 quantity of pathogens 变异性 variability,病原体的致病能力,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(1) 侵袭力,直接侵入人体 invade directly Leptospira, filariform larva of Ancylostoma先黏附于肠或支气管黏膜表面，再侵入组织细胞，如志贺菌、结核分枝杆菌。致泻性大肠埃希菌能表达受体(定植因子)和小肠细胞结合adhere, coloni

21、ze and produce enterotoxin: Vibrio cholera通过细菌表面成分（如伤寒沙门菌Vi抗原）抑制吞噬而促进病原体扩散 promote spread：Vi antigen of Salmonella typhi,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(2) 毒力,毒素 toxins 外毒素 exotoxin (Vibrio cholera, Clostridium tetani, Corynebacterium diphtheriae

22、) 内毒素 endotoxin (S. typhi, Sh. dysentery) 其他毒力因子 穿透能力 filariform larva of Ancylostoma 侵袭能力 Sh. dysenteriae 溶组织能力 Entamoeba histolytica,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(3) 数量,同一种传染病，入侵病原体的数量与致病能力成正比 The number of invading pathogen is positive relat

23、ion with the pathogenicity in the same infectious disease不同的传染病，能引起疾病的最低病原体数量可有较大差异 The least number of the pathogen to induce disease differ greatly in different diseases. For example, S. typhi is 10000 and Sh. dysenteriae is only 10,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of

24、Infectious Diseases,(4) 变异性,变异因素 variation factors 环境 environmental、药物 drug、遗传 hereditary 变异类型 various forms 致病力变异 pathogenicity variation 抗原性变异 antigenic variation 耐药性变异 drug-resistant variation,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,感染过程中的免疫应答,保护性免疫应答：

25、有利于机体抵抗病原体 非特异性免疫 天然屏障 anatomic barriers 吞噬作用 phagocytosis 体液因子 humoral effects 特异性免疫 细胞免疫 cell-mediated immunity 体液免疫 humoral immunity 变态反应：促进病理改变 特异性,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,第二节 传染病的发病机制,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis an

26、d Treatment of Infectious Diseases,一、传染病的发生与发展,入侵部位 position of invasion 机体内定位 location in the body 排出途径 route of exclusion,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,二、组织损伤的发生机制,直接损伤 direct damage 毒素作用 action of the toxin 免疫机制 immunity mechanism,传染病诊治国家重点实验

27、室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,三、重要的病理生理变化,发热 pyrexia 急性期改变 蛋白代谢 糖代谢 水电解质代谢 内分泌改变,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,第三节 传染病的流行过程,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious D

28、iseases,一、流行过程的基本条件,传染源 source of infection 患者 measles 隐性感染者 poliomyelitis 病原携带者 typhoid fever, bacillary dysentery 受感染的动物 rabies, plague, leptospirosis, typhus,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,一、流行过程的基本条件,传播途径 route of transmission 呼吸道传播 消化道传播 接触传

29、播 contagious transmission 虫媒传播 arthropod-bone transmission (blood-sucking arthropods: mosquito, lice, flea, sandfly, mite, tick) 血液、体液传播 blood, blood products and body fluid 其他：mother to infant (vertical transmission),传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseas

30、es,一、流行过程的基本条件,人群易感性 susceptibility of the crowd 易感者 The ratio of susceptible persons decide the crowd susceptibility 流行的周期性 The crowd susceptibility is relation to periodicity of an epidemic 人工免疫影响流行的周期性 The periodicity of an epidemic may be prevented by artificial active immunization,传染病诊治国家重点实验室

31、State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,二、影响流行过程的因素,自然因素 natural factors geography, climate, ecology 疫源地 focus of infection 自然疫源性传染病/人兽共患病 zoonosis (plague, leptospirosis, human avian influenza) 社会因素 social factors social background, economical condition, cultural lev

32、el, anti-epidemic measures,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,第四节 传染病的特征,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,四大基本特征,病原体 pathogens 传染性 infectivity 流行病学特征 epidemiologic feature 感染后免疫 postinfection immuni

33、ty,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(1) 病原体,有特异性 specific 应用新技术可发现更多病原体 Be found with natural science advancements,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(2) 传染性,是传染病与其他感染性疾病的主要区别 Infectivity is the mai

34、n distinction between the infectious diseases and other infection可依据传染期隔离患者 “Infective period” can be used as a rule to isolate the patient,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(3) 流行病学特征,流行性 endemic (sporadic, epidemic, pandemic & epidemic outbreak) 季

35、节性 seasonal distribution in time 地方性 regional distribution in space 外来性 exotic (e.g. cholera and yellow fever),传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(4) 感染后免疫,属特异性、主动、保护性免疫 specific, active, protective, can transfer to newborns through placenta 持续时间在不同传

36、染病中有很大差异 lasting time varies with the diseases 持续时间短可出现再感染、重复感染 “concomitant immunity” (helminthiasis),传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,急性传染病的四期经过,潜伏期 incubation period 前驱期 prodromal period 症状明显期 period of apparent manifestation 恢复期 convalescent pe

37、riod,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(1) 潜伏期,常态分布 normal distribution, as important evidence of observing, detecting the contact in quarantine work随病原体的种类、数量、毒力与人体免疫力的强弱而定 related with invading quantity of pathogens, time of the toxin (bacterial f

38、ood poisoning), wound location (rabies)潜伏期短的传染病，流行时往往呈暴发,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(2) 前驱期,非特异性 nonspecific为许多传染病所共有coexist in many infectious diseases一般持续13天 usually persist one to three days, even miss (sudden onset),传染病诊治国家重点实验室 State Key

39、 Laboratory for Diagnosis and Treatment of Infectious Diseases,(3) 症状明显期,充分表现特有症状和体征 Special symptoms and signs presented enough, such as rashes, jaundice, heptomegaly, splenomegaly, meningeal irritation signs 为许多急性传染病所共有especially in some acute diseases measles & varicella某些传染病可缺如，即顿挫型 abortive typ

40、e poliomyelitis, epidemic encephalitis,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,(4) 恢复期,机体免疫力增长至一定程度，体内病理生理过程基本终止 Immunity increases to a certain level， appetite and physical strength recovered可残余病理改变（如伤寒）或生化改变（如病毒性肝炎），病原体尚未能被完全清除（如霍乱、痢疾）residual pathologi

41、c & biochemical change, infectivity may persist (convalescent carrier)可出现再燃、复发 recrudescence & relapse, the symptoms repeatedly and fever rise again,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,常见的症状与体征,发热 fever：三个阶段、多种热型皮疹 rash：时间、分布、次序、形状毒血症状 toxemic symptom

42、s 单核-吞噬细胞系统反应 MPS,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,第五节 传染病的诊断,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,传染病的诊断依据,临床资料 clinical data 详尽的病史、细致的体检 流行病学资料 epidemiological data 发病年龄、职业、季节、地区，集体发病史 预防接种史、过去史、家族史

43、 实验室检查 laboratory data 常规检查、病原学检查、免疫学检查等,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, 直接检出 microscope or macroscopy,病原学检查,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, 培养分离 cultured or isolated,传染病诊治国家重点实验室 State Key La

44、boratory for Diagnosis and Treatment of Infectious Diseases, 分子生物学检测 分子杂交 hybridization assay 聚合酶链反应 polymerase chain reaction,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, 特异性抗体检测 特异性抗原检测 免疫标记技术 细胞免疫功能检查,免疫学检测,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis a

45、nd Treatment of Infectious Diseases,第六节 传染病的治疗,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,传染病的治疗方法,一般及支持疗法 general and supporting 病原/特效疗法 anti-pathogenic 对症疗法 symptomatic 中医中药 Chinese traditional,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment

46、of Infectious Diseases,第七节 传染病的预防,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,传染病的预防方法,控制传染源 management of the sources of infection 病人：早发现、早诊断、早隔离、及时上报 接触者：检疫、密切观察、药物预防/预防接种 病原携带者：治疗、教育、调整岗位、随访观察 切断传播途径 interruption of the route of transmission 主要针对：消化道传染病、虫媒传染病、寄生虫病 方法：消毒（预防性和疫源性）、杀虫、卫生措施 保护易感人群 protection of susceptible population 特异性主动免疫：疫苗、菌苗、类毒素 特异性被动免疫：抗毒素、丙球、高滴度免球,传染病诊治国家重点实验室 State Key Laboratory for Diagnosis and Treatment of Infectious Diseases,丙 类11种,法定传染病,乙 类26种,甲 类2种,