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Zhang Wenhong's new crown pneumonia review (2): thought it was a black swan, but it was actually a gray rhino
First Financial 2020-02-27 10:53:14
Zhang Wenhong
The best time may be in the first week of January. If you can start a clinical diagnosis or a direct online report of a suspected diagnosis, this should be the last time point in the early stage that the disease can spread widely.
Everyone thought it was a Black Swan incident. We were attacked by the sudden and unpredictable Black Swan incident, and the misfortunes we passed today were all because of bad luck. If we all think so, then we really live up to this crisis and live up to the nation's efforts to make a living.
Today we walked from the darkest moment, but the whole world seems to be back to the time when Wuhan was popular in the early days, so China's review and experience are of vital importance to the world and ourselves .
Review of Wuhan before December 1, last year: the birth of the black swan
According to the current panel's review of early cases, the earliest recorded cases were December 1 and December 8 last year.
Now the whole society is tangled before December 1st? Where is patient 0?
Conspiracy theories are all over the Internet. In short, the three words "don't believe". No patient 0, no so-called intermediate host, I'll be with you.
The author's team sequenced the entire genome of the virus strain that was imported into Shanghai around January 20, and compared with the Wuhan strain, there was no mutation. This conclusion was published in the International Journal of Emerging Microbes and Infections. It is confirmed that the virus said by WHO is still authentic and has not become more virulent or easier to spread .
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The author also read the international team's data on the genome analysis of this new crown virus. In short, molecular biology experts mean that the genetic evolution of this virus must be a bat coronavirus source.
From the classification of the whole genome sequencing results published by the author, you don't understand anything. It can also be seen that this time the virus and the coronavirus carried by the bat are the same family, so it also caused some SARS-like clinical manifestations in 2003. . The new type of coronavirus and bat SARS-like coronavirus (bat-SL-CoVZC45) have more than 85% homology. On February 11, 2020, the International Virus Classification Commission (ICTV) named the virus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).
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But what is certain is that it was estimated to be an accidental chance before December last year, when the virus from bats entered human society.
Humans themselves opened Pandora's box. Now I endure the consequences silently. After the epidemic, I think humans will deeply reflect on this. But now, the origin of the virus (including which wildlife it came from) is not the most important, because it has come to earth.
It was a gray rhino from December 1st to December 30th last year.
Dr. Li Wenliang warned that the incident shocked the world. But from a technical point of view, what exactly did Dr. Li see and let him issue this alert?
From December 1st to December 30th last year, clinicians represented by Dr. Li have actually warned. But this warning failed to produce a systematic scientific report. Reported through conventional channels until the first batch of national expert groups were stationed in early January.
There is nothing wrong with the procedure. But in the early prevention and control of imported diseases, the first and most critical time point was missed.
So why can't clinicians form a systematic scientific report, which can greatly shorten the whole process from warning to implementation?
Academician Wen Yumei and the writer, a famous virologist at Fudan University, often talk about how to build a system for warning. Clinicians are the first pass. The enemy has just arrived at the village entrance. At this time, the alarm is sounded, and the hospital network system of the whole society is quickly established . Just like Singapore today, even if it is controlled by the “Buddha Department”, it can do better than other parts of Asia ( we will talk about the construction of the early system in more detail in the next issues ).
Why did the national direct reporting system for infectious diseases ignite at this time? The reason is that the front-line infectious disease prevention system is not powerful enough to distinguish which signals need to be reported directly and which signals do not need to be reported directly. In the winter, influenza-based viral pneumonia is tens of thousands in each city. Now new crown pneumonia appears and is mixed in. If it is reported, it means that you are calling a wolf every year. Will passivate failure. Only when the outbreak of infectious diseases that form the entire city and the enemy forces fully occupy the city will it start.
Therefore, Dr. Li Wenliang's warning left us with a valuable legacy and made us aware of the shortcomings and vacancies in our country's current early warning system for new infectious diseases.
This loophole is not blocked, and the discovery of new infectious diseases must be after the outbreak, not early.
So, where is this a black swan, this is a solid gray rhino , the danger is always there, and the result of turning a blind eye is horrible once it happens.
What kind of warning system should we establish? You can see the author's discovery of the transboundary transmission of swine herpes virus on the Huashan public account.
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In fact, what we need is not only that Dr. Li Wenliang can see, but all doctors should be able to see this alert, we can greatly move the risk point forward. This is the so-called first safety window, which was opened by Dr. Closed by our own ignorance.
Why did Dr. Li Wenliang see it, but other doctors couldn't? Saw it, but couldn't convince the superior department? Where is the technical link inside? In the review of the later issues, I will talk about the missing technical links in this issue, especially in the last issue of "Living to the Light."
Have we ever had a chance from January 1st to January 24th?
According to the currently available data and published papers, China CDC and Chinese scientists confirmed that this is a new type of coronavirus in the shortest time, and the virus was published in the internationally renowned Lancet Journal and the New England Journal of Medicine, respectively. The genetic structure and potential host receptors have also revealed the main clinical features of the disease. Virus receptors are mainly distributed on the alveolar cells of the lower respiratory tract. This predestined that the dominant disease of the disease is mainly pneumonia. Since the proportion of severe patients is low, and the proportion of mild or asymptomatic diseases may be large, it is very easy to cause great transmission without knowing it. These tasks were fully completed during the first week of January.
But until January 20, when the National High-level Expert Group announced the existence of human-to-human cases, did we still have enough security windows to fight the epidemic? In fact, the number of cases in Wuhan had increased significantly at that time, and no simple and effective rapid diagnostic method was established at this time. At the time, reporting of new coronary pneumonia across the country also required full-gene sequencing data, which brought technical obstacles to the direct reporting of the disease on the Internet.
In fact, the best time may be in the first week of January. If the direct diagnosis of clinical diagnosis or suspected diagnosis can be started, this should be the last time point in which the disease can be widely spread in the early stage.
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January 24-present, reviewing the strategy of closing the city and its subsequent trends
On January 24, after the city was closed in Wuhan, all provinces and cities across the country started a first-level response, and the national battle against new crown pneumonia started in an all-round way. Wuhan has implemented unprecedented measures to close the city, and other provinces and cities across the country have also adopted a number of measures, including strict prevention of imported cases, fever screening and screening, crossing control, community control, traffic epidemic prevention, and public place epidemic prevention. The entire Wuhan has undergone a LOCK DOWN, and the entire Chinese SLOW DOWN has come down. As a result, everyone has seen that the epidemic in China was effectively controlled within one month.
The data will not deceive, but in the early days of Wuhan ’s closure, many foreign public health scholars and flu experts have analyzed that the LOCK DOWN of external traffic in a region can only delay the peak of the epidemic and not completely stop the arrival of the epidemic. Are these experts wrong? No, because their analysis is based on the most rigorous mathematical model. Are these experts correct? Nor is it, because in their mathematical model, an important factor is ignored, that is, the potential for revision and improvement of an urban epidemic prevention system. It was during this period of delay in the precious epidemic that was created after the city was closed. China, a country that is good at learning and hard work, took advantage of the national system to quickly respond to it. The epidemic prevention system was re-established in an all-round way, and the epidemic situation was initially controlled during this precious window period.
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China's warning system is certainly imperfect, but China has the fastest self-correction effort. Behind this is the advantage of the national system, and it is also a demonstration of the unselfish dedication of countless medical workers, government functional departments, community workers, workers in other industries, volunteers, and the public. And these cannot be estimated by mathematical models.
Admittedly, this is not the best result, and we hope to establish an earlier and better direct reporting system in the future. In that case, everything may be killed earlier, and "slightly Buddhist control" can achieve the same result. However, there is no one-size-fits-all answer to the prevention and control of infectious diseases. The policy of each country should be based on its current medical resources and the actual situation of epidemic changes to make the most correct choice (a detailed analysis will be discussed with you in later issues). As the WHO inspection expert group said: " It is precisely because China has adopted this classic traditional, seemingly old-fashioned method of the entire government and society that it has avoided the occurrence of as few as tens of thousands and as many as hundreds of thousands of cases. This is an amazing achievement. "
Wuhan is a heroic city, and its sacrifice has won a valuable window for the whole of China. And China's efforts have also given the world time to understand the virus and the spread and clinical characteristics of the disease. Next, whether the respective prevention and control systems of the countries in the world can effectively curb the epidemic of new crown pneumonia will become the new key. The joint defense in Europe and the strong control in East Asia will also be rapidly implemented based on their national conditions. And we also expect that when the spring flowers bloom, the global village will be far away from the virus and show their joy.
Wen / Zhang Wenhong (Leader of Shanghai Medical Treatment Experts Group, Director of Infectious Diseases Department of Huashan Hospital)
This article is reproduced from the "Huashan Infection" public account with authorization, and the copyright belongs to the Department of Infectious Diseases, Huashan Hospital, Fudan University.
Editor-in-chief: Ren Shaomin
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