Original title: new crown “Fuyang” suspected Yunyun
Nucleic acid test of patients with new crown pneumonia again positive after discharge from hospital, posing new challenges to epidemic prevention and control.
The latest data shows that as of 24:00 on March 4, 31 provinces (autonomous regions, municipalities) and the Xinjiang Production and Construction Corps currently reported a total of 80,409 confirmed cases, of which about 0.1% were “Fuyang” cases after discharge.
On March 5th, Zhijun Jun interviewed several authoritative experts and learned that in addition to objective factors such as kits and sampling methods, which are “false negatives”, there are still virus residues or main causes in patients, and patients may be intermittent. Detoxification.
Monitoring by the National Health and Medical Commission found that “Fuyang” patients did not infect others. However, for the new virus New Coronary Pneumonia Virus, its pathogenic mechanism, disease profile and course characteristics need further research and understanding.
Until the suspected cloud of “Fuyang” is cleared, prevention and control is tightening. On March 5th, there was a square cabin hospital in Wuhan receiving information from Wuhan Command, saying that all square cabin hospitals in Wuhan had suspended discharge of patients. Some cabin hospitals take blood samples from patients for viral antibody tests.
On March 4th, the latest version of the National Health and Medical Commission ’s latest version of the diagnosis and treatment plan added the requirement of “should continue to carry out 14-day isolation management” after discharge, and localities have also raised their discharge standards on the national version.
Experts suggest that how to properly detect and effectively manage requires careful judgment and seek a balance between all parties.
Are there many cases of “Fuyang” at present?
“Fuyang” cases accounted for about 0.1% of all cases.
Recently, Guangdong, Sichuan, Hubei, Hunan, Tianjin, Jiangsu and other places have shown cases of positive nucleic acid re-examination in discharged cases, that is, “Fuyang” after discharge.
On March 2nd, Tianjin Health Construction Commission reported that the 20th and 121 confirmed cases in Tianjin were positive for nucleic acid re-examination during the period of centralized isolation and observation after discharge, and have been transferred to Haihe Hospital for observation. On February 29th, it was notified that the 29th and 43 confirmed cases in Tianjin were positive for nucleic acid re-examination during the centralized isolation and observation after discharge, and have been transferred to Haihe Hospital for observation and treatment.
The Beijing News previously reported that on February 29, a 6-year-old boy in Tianjin was discharged from the hospital 10 days after he was discharged from the hospital. He was found to have the virus in the intestine, that is, the anus swab was turned positive and was admitted to the hospital.
On March 1, Hainan’s first “Fuyang” patient was successfully discharged. After the patient Yi Moumou was discharged on February 19, he was admitted to the Changjiang designated hospital for 14 days. He was admitted again because of a positive swab test. After treatment by the People’s Hospital of Hainan Province, the patient’s temperature returned to normal for 5 days, and the respiratory symptoms improved significantly. A review of the lung CT revealed that the acute exudative lesions were clearly absorbed. Pharyngeal swabs and fecal nucleic acid tests were negative twice (with an interval of more than 24 hours).
On the morning of February 24, Mr. Wang and his family, the first patient with new-coronary pneumonia in Xuzhou, Jiangsu, finally returned home. Previously, he had received 15 days of medical rehabilitation and 14 days of fixed-point isolation.
When Mr. Wang returned home, the community held a welcome ceremony for him. Mr. Wang, who was discharged from hospital for half a month, was re-examined for nucleic acid. He was again hospitalized for treatment. The close contacts were quarantined and his family unit was closed for another half a month.
On February 24th, Zhang Ye, Department of Respiratory and Critical Care Medicine, Wuhan University People’s Hospital, published a “Preliminary Statement on” Removal of Isolation and Discharge Standards “on WeChat public account of the department. He proposed that the hospital would meet the national discharge standards A total of 18 people were discharged from hospital, and the pharyngeal swab nucleic acid was re-examined a total of 5 times, and 13 patients showed positive results for the third time.
On the afternoon of February 25, at the Guangdong Provincial Epidemic Prevention and Control Conference, Song Tie, Deputy Director of the Guangdong Provincial Center for Disease Control and Prevention, introduced a total of 13 “Fuyang” In the case of 104 close contacts, no infection occurred. Preliminary data from the Guangdong Province showed that 14% of discharged patients also had “Fuyang”.
On the evening of March 4, Tong Zhaohui, a member of the central expert group of the Central Guizhou Steering Group and an expert in respiratory critical illness, said on CCTV that there are now about 80,000 cases in the country. In fact, the proportion of these re-positive cases after discharge is about 0.1%. No matter how you calculate them based on the mean, standard, and standard deviation, they are in a controllable range.
Why is there “Fuyang”?
Or because the patient still has virus residues
, Zhang Liming, a member of Beijing Aid Wuhan Medical Team and chief physician of the Department of Respiratory and Critical Care at Beijing Chaoyang Hospital, said that during the first-line treatment of patients with new coronary pneumonia, several nucleic acid tests were performed on some patients. Negative and positive effects appear. Therefore, it is not surprising that “Fuyang” appeared after discharge.
Jiang Rongmeng, a member of the expert group of the National Health and Health Commission, believes that the greatest possibility of “Fuyang” is not that the patient re-infects after healing, but that there is always a virus residue in the body.
He said that the discharge standards for patients with new coronary pneumonia have been exploring. Currently, discharged patients need to meet four criteria: body temperature, respiratory symptoms, nucleic acid testing, and pulmonary imaging to show inflammation. But for now, for many reasons, meeting discharge standards does not mean complete recovery.
On the one hand, the patient must be negative for both nucleic acid tests before discharge, but during the sampling of the throat swab, the sampling site, sampling method, and sensitivity of the reagents may affect the positive rate.
On the other hand, the duration of viral pneumonia inflammation absorption is longer than that of bacterial pneumonia, and the true condition of the patient’s lungs is also difficult to grasp. In the later recovery period, it is not good to judge whether it is inflammatory exudation or absorption or pulmonary fibrosis from CT.
Tong Zhaohui introduced in an interview with CCTV that the discharged patients were “Fuyang”. This was not a re-infection, but a positive again. From an objective point of view, the detection of nucleic acid by the kit is still not stable, and there is also a problem of detection sampling.
The Beijing News has interviewed several experts to explore the “false negative” doubts. The new guidelines for laboratory testing of new coronary pneumonia issued by the National Health Commission also point out that negative results cannot rule out new coronavirus infections, and factors that may cause false negatives need to be excluded, including: poor sample quality, such as respiratory tract samples from the oropharynx; The samples were collected too early or too late; the samples were not properly stored, transported, and processed; the reasons for the technology itself, such as virus mutations, PCR inhibition, etc.
In addition to “false negatives” caused by objective factors such as kits and sampling methods, Tong Zhaohui also previously introduced that there may be some patients who use hormones for a long time and in relatively large quantities. His virus removal from the body will be delayed, that is, the test is “True negative”, it will still be positive when tested again. Song Tie, deputy director of the Guangdong Provincial Center for Disease Control and Prevention, said that patients may have intermittent detoxification. In short, “true negative” does not mean that the virus is completely cleared from the patient.
At the news briefing for the special prevention and control of epidemic situation in Guangzhou on February 27, Zhong Nanshan, an academician of the Chinese Academy of Engineering, said that there were many reasons for the nucleic acid test “Fuyang” of discharged patients, which may be the problem of the reagent itself, and the detection methods and sampling methods will also affect Positive rate, “Fuyang” patients may not have been negative before. It is reported that in response to the “Fuyang” situation, Guangdong is currently working with the Zhong Nanshan team to strengthen research in this area.
Will “Fuyang” patients infect others?
Depending on various factors such as the amount of virus, further research is needed.
Jiang Rongmeng introduced. In theory, if a live virus can be isolated in a patient, it means that it is contagious. However, a positive nucleic acid test for discharged patients is not necessarily a live virus, and there may be a possibility that the virus has been destroyed and the gene fragments are excreted.
In addition, the magnitude of infectivity depends on a number of factors. Generally speaking, the more severe the patient’s symptoms, the greater the amount of virus in the body, and the greater the amount of detoxification. When the symptoms weaken, the amount of virus decreases, and the infectivity decreases accordingly. If protection measures such as isolation and masks are added, the theoretical risk of infection is very low. However, these need to be further studied.
Zhong Nanshan believes that there are many reasons for the nucleic acid test “Fuyang” of discharged patients. Generally, the cured patients who produce antibodies will not be infected again, but it is worth noting to observe whether they will infect others.
On February 28, at a press conference organized by the joint prevention and control mechanism of the State Council, Guo Yanhong, the supervisor of the Medical, Political, and Medical Administration of the State Health and Health Commission, introduced that through monitoring, it was found that “Fuyang” patients did not re-infect others. Some patients turned negative when they were tested for the new coronavirus. Experts are being organized to study this issue, and continuous monitoring of these cases is also being strengthened.
However, she also pointed out that the new crown pneumonia virus is a new virus, and its pathogenic mechanism, disease profile and course characteristics need further understanding. Therefore, on the one hand, it is necessary to further strengthen the management of discharged patients. Now it is required to strengthen follow-up, health monitoring and health guidance in the implementation of 14-day medical observation. At the same time, experts are organized to conduct further research to further understand the entire process of the occurrence, development and outcome of the disease.
to deal with “Fuyang”?
Experts suggest judging whether to raise discharge standards carefully. For
“Fuyang”, some voices believe that the number of nucleic acid tests on discharged patients should be increased, or other detection methods should be added to raise the threshold for discharge.
Zhang Ye suggested in the above WeChat account article that 3 consecutive negative discharges are more reliable, and suggested that the New Coronary Pneumonia Diagnosis and Treatment Program will modify Article 4 of the standard for isolation and discharge to 3 consecutive negative nucleic acid tests for respiratory specimens.
Zhong Nanshan previously suggested that a positive result could be found after being discharged from the hospital for isolation at home, and it could be checked again after 24 hours. If it turned negative, it might be a technical problem. If it is still positive, return to the hospital for close observation.
Jiang Rongmeng introduced to Zhijun today that increasing the number of nucleic acid tests or other detection methods, which involves the adjustment of the overall prevention and control strategy, is relatively complicated and should be judged with caution. New crown pneumonia has a great impact on people’s life, work, including the entire workforce. If the time is longer, the impact will be even greater.
He said that if the threshold for discharge is raised, the follow-up options will also be faced. Most of the patients with new coronary pneumonia are mild. In the later stage, some people may not need treatment. If they are left in the hospital just for isolation, medical resources will be tested. Occupied resources may affect those who require regular medical treatment. Infected patients.
“We need to weigh the consequences. We need government departments and experts to seriously discuss the matter and consider this as a whole. How to properly detect and effectively manage it. We must consider the secondary effects of the epidemic and find a balance between all parties,” Jiang Rongmeng said.
Zhong Nanshan also previously proposed in an interview with CCTV that for some patients with negative throat swab tests, but positive stool tests, we recommend hierarchical management and close observation. He believes that if the current testing standards are adjusted, the patient’s anal swab test results will also be completely negative, which will easily cause the patient’s backlog and affect subsequent diagnosis and treatment.
How to develop discharge criteria exactly?
Anal swabs and antibody tests have been added to the national standard in many places.
Up to now, the National Health Commission has developed a total of seven versions of diagnosis and treatment programs. In the diagnosis and treatment plan, the criteria for desegregation and discharge were changed several times. The first five editions did not explicitly require patients to monitor and observe after discharge. The sixth edition requires patients to continue their 14-day self-health monitoring after discharge. The seventh edition specifically adds “14-day isolation management” to the “Fuyang” situation.
In the third edition of the diagnosis and treatment plan released on January 23, there were four requirements for the release of isolation and discharge standards, including: the body temperature returned to normal for more than 3 days, respiratory symptoms improved significantly, pulmonary imaging showed significant absorption of inflammation, and two consecutive respiratory tracts Pathogen nucleic acid test is negative (sampling interval is at least 1 day). Meeting these four requirements can be released from the hospital or transferred to the appropriate department for other diseases according to the condition.
On January 27th, the National Health and Medical Commission issued the fourth edition of the diagnosis and treatment plan, which reduced the isolation and discharge standards by one item, and no longer needed to meet the “pulmonary imaging shows obvious absorption of inflammation”.
On February 5, the fifth edition of the diagnosis and treatment plan was released. In the standard for isolation and discharge, the body temperature returned to normal for more than 3 days, the respiratory symptoms improved significantly, and the negative nucleic acid test for respiratory pathogens was negative twice (sampling interval at least 1 day). On the basis, it was added again that “pulmonary imaging shows significant absorption of inflammation”.
On February 19th, the “Post-discharge Notes” was added to the release of isolation and discharge requirements for the sixth edition of the treatment plan. Among them, after discharge, patients are at risk of being infected with other pathogens due to their low immune function during the recovery period. 14-day self-health monitoring, wearing a mask, conditionally living in a well-ventilated single room, reducing close contact with family members, sharing meals, doing good hand hygiene, and avoiding outing activities. At the same time, it is recommended to follow up and return to the hospital in the 2nd and 4th week after discharge.
On March 4, the seventh edition of the diagnosis and treatment plan changed the “dissociation standard” to “discharge standard”. There were still 4 discharge standards, and the first 3 were unchanged. Article 4 added “sputum, nasopharyngeal swabs, etc.” airway nucleic acid test for two consecutive negative, the sampling time was at least “interval of 1 day”, changed to “at least 24 hours”. This means that meeting discharge standards does not relieve segregated observation.
In response to the “Fuyang” situation, the latest version of the plan also proposes that in view of the fact that a small number of discharged patients have positive nucleic acid test retest results, in order to strengthen the health management and isolation of discharged patients, “the 14-day self-health monitoring should continue” It should be changed to “Should continue to carry out 14-day isolation management and health monitoring”. At the same time, it is required to wear a mask and live in a well-ventilated single room conditionally to reduce close contact with family members, share meals, and do good hand hygiene. Avoid outing activities.
That is, on the basis of the 14-day self-health monitoring in the sixth edition, a “14-day quarantine management” was added, requiring further tightening.
At present, some provinces have improved their discharge and release standards based on the international version of discharge and release.
According to reports, Hubei requires that patients treated with New Crown Pneumonia be cured and discharged from hospital to complete a 14-day free rehabilitation isolation and medical observation at designated places. Until March 5th, several square cabin hospitals in Wuhan have suspended the discharge of patients. On the evening of March 4, Wuhan Jiang’an Fangcai Hospital issued an “Emergency Notice”: According to the latest notification from the Municipal Epidemic Prevention Headquarters, there were more relapsed patients recently discharged, resulting in patients being re-admitted to hospital for treatment. In order to ensure that everyone is completely cured and achieves the goal of “zero turnaround”, the hospital research decided to take a blood test on all the patients who are going to be discharged from the cabin and check the virus antibodies Ig-M and Ig-G to ensure that the patients are completely discharged. From March 5th.
So far, none of the patients recovered from Shanghai’s New Crown Pneumonia appeared “Fuyang”. After patients with Shanghai New Coronavirus infection have two negative nucleic acid tests, they will be tested for anal swabs to ensure that they will not re-positive after recovery.
Guangdong requires that the relevant requirements for discharge standards be accurately grasped on the basis of the national diagnosis and treatment plan and the consensus of Guangdong local experts. Discharged patients were collected and observed in local medical institutions for at least 14 days after discharge. The nasopharyngeal swab + anal swab nucleic acid test was reviewed on the 7th and 14th days. After discharge, the cases of “Fuyang” with nucleic acid detection will be admitted to the hospital for treatment and related examinations and treatments.
Reporter Deng Qi Dai Xuan