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欽差與防疫 (之四)絲襪玉腿
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鏈結文章欽差與防疫 (之一):反面教材

    欽差與防疫 (之二):麻雀雖小

    欽差與防疫 (之三):真刀真槍

    欽差與防疫 (之四):絲襪玉腿

    欽差與防疫 (之五):舞臺動作

    欽差與防疫 (之六):毒氣東來

    欽差與防疫 (之七 / 總結):反智探源




(四):絲襪玉腿


(錯誤二)(臺灣土石流災區)應該全面實施疫苗接种,救灾人员要先期注射才可去救灾。

請問打什么疫苗?哪一種?或者哪幾種?

如果疫苗指的是H1N1超流,第一,此時不會爆發夏季流感已如前述,第二,八月風災時,全世界都還沒有 H1N1 疫苗,照流行病學規劃時程,臺灣原訂十月推出。請問欽差,疫苗在哪里? (《H1N1 流感疫苗》另文討論)

如果疫苗指的不是H1N1,那是指傳統傳染病(參看法定傳染病列表),此時不夠施打的條件,因為鼓噪而施打是專業不敵民粹。

另外,《救災人員打完疫苗才可以進入災區救災》不知有何根據?聽來倒令人生武俠小說聯想,頗具娛樂效果,---先吃了解酒藥,再下場拼酒,果然千杯不醉。

蓋傳統疫苗的作用機轉,是注射殺死的 (killed) 或減毒的(attenuated)病菌抗原 (antigen),激活免疫系統,制造保護抗體,所以免疫。要產生足夠強度的抗體,需等待一段時間,時間視抗原性質而定,case by case, 至少兩周多則兩月(像B型肝炎疫苗,不但須打好幾次,而且還要等半年以上才見效),要打完疫苗再救災,是等兩周呢?還是兩個月呢?還是欽差另有仙丹可以立即見效,吃罷千杯不醉?

我們且慢對疫苗細說從頭,不如先搞清十萬火急強求疫苗的心病何在?心病是恐慌!以為大疫將至,而慌不擇路,饑不擇食。即欽差所謂《大災之后必有大疫》。大疫爆發于毀滅性災難之后,并非絕無可能,但卻須以該社區平時的全民免疫等級應對。若災變地點,原本全民免疫缺斤少兩,災難將雪上加霜,若全民免疫早已逐步組建,此時正是驗收時刻,并無“加映一場”之必要。天災之后,因慌不擇路、自作主張、毀掉辛苦半世紀才建立的全民防疫長城,才是人謀不臧。

把疫苗當萬金油,在無知而焦急的災民中很常見,而這種大難將至饑不擇食的心態,可以不由分說,變成暴動,美國2005八月的Katrina風災后,災變中心就深受其害,請看《Katrina 風災后傳染病防範要點》, (附錄一)(官方文獻,全文照列):

首先,官方公告文中的黑體字是原版,并非 yichun 修改,你們說,官方為什么特別把這幾行加註黑體?因為謠言造成的盲動,比傳染病更可怕。這個公告很「實際」,目的在解決問題,解決什么問題?止謠解惑,化解恐慌,預防暴動。

1) 官方宣導文不是勸導接受疫苗注射,而是說明沒有注射的必要。

2) 謠言集中兩項:
A).
漂流腐爛的屍體(死雞死豬和死人!)將引來大疫。
B).
廢污水橫流將產生霍亂傷寒。

3) 關于屍體:飲水污染,有可能造成腹瀉和呼吸道感染,但絕非致命性傳染病。

4) 關于霍亂傷寒:傳染病再可怕,沒有菌源無法成疫。謠言雖甚囂塵,但霍亂傷寒在路易斯安那早已消滅禁絕幾十年,不會因水災無端冒出!

比較《卡翠娜》和《莫拉可》可以發現,災民之病,中外皆然,都信名嘴甚于專家。都因恐懼爭求疫苗,都把疫苗當萬金油,都以為疫苗是即溶咖啡,甚至連謠言里的傳染病主角,都選擇霍亂傷寒!這背后都未覺察的原因是疾病的《印象》。卡繆(Albert Camus)的黑死病(The Plague)是鼠疫印象。毛姆 (Somerset Maugham) 的華麗的面紗(the painted veil)是霍亂印象。亂世佳人的亞特蘭大火車站,是菌血症和截肢印象(sepsis & amputation),魯迅的祥林嫂,是傷寒印象(Typhoid fever)。印象其實是「硬像」,stereotype! 不受客觀事實限制,根深蒂固。

1962 臺視開播,早期黑白電視里的醫生都戴耳鼻喉科頭鏡,后來有個導播變成我病人,我問他你怎么那么喜歡耳鼻喉科?他老實承認,演員穿了白袍還是只像理髮師傅,《望之不似人君》,沒辦法,只有“掛滿勛章演將軍,增加說服力”,而頭鏡至少是他心目中的“內行擺飾”,我說印象呀印象,象腿穿了玻璃絲襪,就是玉腿了?遂大笑解嘲……對于觀眾,疾病是一個印象,印象不在 Cecil, Harrison 的內科學裡,印象在揮之不去的噩夢裡,從梁山伯到茶花女,死前都是吐血,蓋 TB/結核病深入人心,不吐血如何打動觀眾?不吐點兒血如何堆砌重病印象?

所以導播說:來,快給他(她)涂點兒番茄醬!

所以欽差說:來,快給他們打點兒疫苗!




再來請看第二份參考文件,這是聯邦政府疾管局(Fed Gov CDC)《風災后災民預防注射推薦表》。(附錄二)

1) 水災固然慘烈,但路易斯安那區事前卻非蠻荒,而為全民免疫組建完備的高度開發區,本區防疫重點在修補全民免疫網漏洞,而非追加額外注射。

2) 區分成人與兒童兩組,因成人已完成所有注射,兒童則正在按部就班接種之中。目的都在回歸水災前正常狀態。

3) 兒童依照病歷之接種記錄 (immunization records) 各就各位。若紀錄完整,應直接歸隊(恢復常態接種),若紀錄不詳者,取最大可能插隊(切入常態接種流程)。

疾管局的預防接種說帖,其防疫應戰邏輯清楚,是要將“非常狀態”回歸“一般狀態”。仔細看【附錄二】裡非屬常態的技術要項有二:

1) 水災后產生防疫工作的最大漏洞來自醫院病歷與各小學健保紀錄同時泡湯(全區域醫院學校同時淹沒)使得修補預防注射網喪失科學依據(尤其兒童)。

2) 唯一災變后視需要酌情加打的預防針是破傷風(DPT),(因風災后清理污泥搬運垃圾修繕房舍,各種意外增加,破傷風疫苗可適度防範傷口感染)。

我的閱讀心得是:

防疫是長期工作,以預防接種而產生免疫有一定時程,不可能臨渴掘井。組建全民免疫網,是種樹,不是即溶咖啡。不可能一碗就吃胖。

Katrina 是毫無預警的晴天霹靂,對于醫療隊伍:他們到底有多大本事?《養兵千日,用兵一時》,現在是尖銳的抽考。對于多年來組建的全民防疫網,“免疫的長城”,到底有多少實效?《一翻兩瞪眼》,現在是驗收時刻。

進入災區的救難人員,如士兵,醫護,消防隊都已有良好的常態免疫,不需增加額外注射。蓋施打沒有必要的疫苗,既無實質防疫功效,又浪費資源,徒增滋擾。大陸汶川大震後,災區一片劫后,亦無自亂陣腳的“隨興式注射”,負重40公斤跑步趕赴災區的救援士兵,感動全世界,也未見《先期注射才准進入災區》。說明大陸公衛醫療也遵循專業運作,可見欽差之荒謬無知,在大陸也是垃圾。

欽差急著上網發文,意在趕新聞熱點,擠進UDN頭版,進軍臺灣文壇。憤青對疫苗一竅不通,卻對臺灣指點江山,蓋因當局對風災應變有隙,遭名嘴太上皇圍剿,《外面鬧洪水,裡面鬧口水》,乃啟佞妄者僥幸之心,以為自己不世英才,應該出馬指導臺灣。淺妄者之悲,悲在不自覺其淺妄,一個連國中健康教育常識都不夠份的二百五,竟自我作聖,對臺灣的公衛政策說三道四?

金庸筆下小童張無忌中了寒冰掌,師祖張三丰見無力救亡,乃同意明教把他帶去找蝶谷醫仙胡青牛,死馬當活馬醫,胡因門戶之見對武當全無好感,治療張只因對疑難雜症著迷,張無忌年紀雖小卻也倔強,對胡也針鋒相對全無示弱,胡治病兼說些醫理自娛,張輸人不輸陣,就自己道聽途說醫學皮毛信口開河傾囊而出,以示《這些我武當派也懂,沒什么了不起》,列寧說:一個傻瓜問的問題,十個天才也答不了。胡空有滿腹絕學卻對一個小孩子說不清楚,答的手忙腳亂,等到弄明白這小子實在什么也不懂,大呼冤枉,但已口乾舌燥……。

張無忌對著蝶谷醫仙明知不敵,卻信口開河,只為逞強:《這些小技,我武當派也會!》

欽差二百五對著臺灣公衛明知自己無料,卻也說三道四,也是逞強:《救災小技,我80后憤青也會!》




下接 《欽差與防疫 (之五):舞臺動作 》



(附錄一)卡翠娜風災后官方公布對民眾的宣導: 傳染病說帖


After a Hurricane: Key Facts About Infectious Disease

Although infectious diseases are a frightening prospect, widespread outbreaks of infectious disease after hurricanes are not common in the United States. Rare and deadly exotic diseases, such as cholera or typhoid fever, do not suddenly break out after hurricanes and floods in areas where such diseases do not naturally occur.

Communicable disease outbreaks of diarrhea and respiratory illness can occur when water and sewage systems are not working and personal hygiene is hard to maintain as a result of a disaster. However, no disease outbreaks have been reported as of September 3, 2005 in areas affected by Hurricane Katrina.

· Decaying bodies create very little risk for major disease outbreaks.

· Outbreaks of infectious diseases following hurricanes are rare in developed countries (such as the United States) and only slightly more common in the developing world.

· Numbers of short-term, self-limiting gastrointestinal illnesses and respiratory infections sometimes increase in developed countries. However, numbers of communicable diseases (including gastrointestinal and respiratory illnesses as well as cholera and typhoid) more typically do not increase in either developed or developing countries.

· Unless a disease is brought into a disaster area from elsewhere, any outbreaks that occur are almost always from diseases that were already in the disaster-affected area before the disaster struck.

· Because cholera and typhoid are not commonly found in the U.S. Gulf States area, it is very unlikely that they would occur after Hurricane Katrina.

· Communicable disease outbreaks can occur when sanitation and hygiene are compromised as a result of a disaster.

· As has been the case in past hurricanes, the U.S. Department of Health and Human Services quickly sets up tracking systems that monitor illnesses in hurricane-affected areas. In the unlikely event that a disease outbreak occurs, these systems provide an early warning that enables prompt public health response.


(附錄二)聯邦政府疾管局(Fed Gov CDC) 對風災后預防接種的說帖。


DISASTER RECOVERY INFORMATION

Interim Immunization Recommendations for Individuals Displaced by a Disaster

The purpose of these recommendations is two-fold:

  1. To ensure that children, adolescents, and adults are protected against vaccine-preventable diseases in accordance with current recommendations. Immunization records are unlikely to be available for a large number of adult and child evacuees. It is important that immunizations are kept current if possible.
  2. To reduce the likelihood of outbreaks of vaccine-preventable diseases in large crowded group settings.

I. Recommended Immunizations

If immunization records are available:

Children and adults should be vaccinated according to the recommended child, adolescent, and adult immunization schedules.

See the following:

If immunization records are not available:

Children aged 10 years and younger should be treated as if they were up-to-date with recommended immunizations and given any doses that are recommended for their current age. This includes the following vaccines:

  • Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
  • Inactivated Poliovirus vaccine (IPV)
  • Haemophilus influenzae type b vaccine (Hib)
  • Hepatitis B vaccine (HepB)
  • Pneumococcal conjugate vaccine (PCV)
  • Measles-mumps-rubella vaccine (MMR)
  • Varicella vaccine unless reliable history of chickenpox
  • Influenza vaccine for all children 6-59 months of age, and all children 6 months through 10 years of age with an underlying medical condition that increases the risk for complication of influenza (MMWR 2006 Jul 28;55[RR10]:1-42).
  • As of May 2006, Hepatitis A vaccination is recommended for children 1 year of age and older in the United States (MMWR 2006 May 19;55[RR07]:1-23).
  • Rotavirus vaccine

Children and adolescents (aged 11-18 years) should receive the following recommended immunizations:

  • Adult formulation tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap)
  • Meningococcal conjugate vaccine (MCV) (ages 11-12 and 15 years only)
  • Influenza vaccine for all children 6-59 months of age, and all children 6 months through 10 years of age with an underlying medical condition that increases the risk for complication of influenza (MMWR 2006 Jul 28;55[RR10]:1-42)

Adults (over 18 years of age) should receive the following recommended immunizations:

  • Adult formulation tetanus and diphtheria toxoids (Td) if 10 years or more since receipt of any tetanus toxoid-containing vaccine.
  • Pneumococcal polysaccharide vaccine (PPV) for adults 65 years of age or older or with a high risk condition (MMWR 1997 Apr 4;46[RR-08]:12-13)
  • Influenza vaccine (MMWR 2006 Jul 28;55[RR10]:1-42)

School requirements

It is not necessary to repeat vaccinations for children displaced by the disaster, unless the provider has reason to believe the child was not in compliance with applicable state requirements.







下接 《欽差與防疫 (之五):舞臺動作 》



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