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猴痘病毒如何颠覆了科学家的认知

This Is Not the Monkeypox That Doctors Thought They Knew
猴痘病毒如何颠覆了科学家的认知

Early in the monkeypox outbreak, a man in his 20s arrived at an emergency department in Northern California, tiny blisters on his lips, hands and back. Within 12 hours, doctors diagnosed him with monkeypox.

在猴痘疫情之初,一名20多岁的男子来到北加州的急诊室,他的嘴唇、手部和背部都长了小水泡。不到12个小时,他就被医生诊断患上了猴痘。

That’s where their certainty ended. The patient did not have fever, aches, weakness, pain or other symptoms typical of the disease. He did not know when or how he had become infected. He had not had sexual contact with anyone for months, he said, and had not touched — as far as he knew — anyone with pox, as the lesions are called, or other symptoms.

但医生们能确定的也只有这些了。该患者无发热、不适、虚弱、疼痛或其他典型疾病症状。他也不知道自己何时或如何被感染。他说自己几个月以来都没有和任何人发生过性接触,据他所知也没有触碰过任何有这种痘疹或其他症状的人。
 

迪米·奥戈伊纳是尼日利亚一项猴痘病例研究报告的作者,该研究记录了不寻常的新症状。“如果欧洲和北半球没有出现这些传播情况,我不认为那篇论文会引起什么讨论,”他说。

At the onset of the outbreak, scientists thought they knew when and how the monkeypox virus was spread, what the disease looked like and who was most vulnerable. The 47,000 cases identified worldwide have upended many of those expectations.

在疫情初期,科学家们以为自己已经了解猴痘病毒是何时以及如何传播的,也清楚这种疾病的症状以及谁最容易受到感染。但全球确诊的4.7万例病例颠覆了他们的许多预期。

Monkeypox patients have turned up with what looked like mosquito bites, pimples or ingrown hairs, not the large pustules usually associated with the infection. Some did not even have visible lesions but felt excruciating pain when swallowing, urinating or emptying their bowels.

猴痘患者出现的症状与蚊虫叮咬、丘疹或毛发内生相似,并不像通常与感染相关的大脓疱。有些人甚至没有明显病变,但会在吞咽、排尿或排便时感到剧痛。

Some had headaches or depression, confusion and seizures. Others had severe eye infections or inflammation of the heart muscle. At least three of the six deaths reported so far were linked to encephalitis, an inflammation of the brain.

一些人会出现头痛或抑郁、思维混乱和癫痫等症状。还有一些人则出现了严重的眼部感染或心肌炎。在目前报告的六例死亡中,至少三例与脑炎有关。

“We really are seeing a very, very wide range of presentation,” said Dr. Boghuma Titanji, an infectious disease physician at a clinic in Atlanta that serves people living with H.I.V.

“我们看到的疾病表现的确非常、非常广泛,”博古玛·泰坦吉博士说,她是亚特兰大一家为艾滋病毒感染者服务的诊所的传染病医生。

Scientists now know that the monkeypox virus lurks in saliva, semen and other bodily fluids, sometimes for weeks after recovery. The virus has always been known to spread through close contact, but many researchers suspect the infection may also be transmitted through sex itself.

科学家们现在知道,猴痘病毒潜伏在唾液、精液和其他体液之中,有时在人康复数周后依然存在。这种病毒一直被认为通过密切接触传播,但许多研究人员怀疑这种感染也可能通过性行为本身传播。

The California patient had virus in his throat, but no respiratory symptoms, and in his rectum, but without pain or pox. The case underscores other research suggesting that the virus may be spread even by people with atypical or asymptomatic infections, said Dr. Abraar Karan, who diagnosed the patient and published a recent case report.

那位加州患者的喉咙中发现了病毒,但他没有呼吸道症状;他的直肠中也有病毒,但没有出现疼痛或痘疹。阿布拉尔·卡兰博士对该患者进行了诊断,并发表了一份最新病例报告,他说,该病例突显了其他研究的结果,即便是非典型或无症状的感染者,也有可能传播这种病毒。

In another study, also published this month, anal swabs of 200 men without symptoms turned up 13 who were positive for monkeypox. Only two of them later developed symptoms.

在另一项同样于本月发表的研究中,200名无症状男性在接受拭子检查后发现其中13人为猴痘阳性。这13人中只有两人后来出现了症状。

“It’s no longer correct to say it can’t be transmitted asymptomatically,” said Dr. Chloe Orkin, an infectious disease physician at Queen Mary University of London. “I think that it means that our working model of how it’s spread is incorrect.”

“没有症状就不会传播的说法已经不对了,”伦敦大学玛利皇后学院的传染病医生克洛伊·奥金博士说。“我认为,这意味着我们现行的病毒传播模式是不准确的。”

Early in the outbreak, the C.D.C. said that “people who do not have monkeypox symptoms cannot spread the virus to others.” The agency changed that phrasing on July 29 to say that “scientists are still researching” the possibility of asymptomatic transmission.

在猴痘疫情初期,美国疾控中心表示“没有猴痘症状的人不会将病毒传给他人”。该机构在7月29日改变了措辞,称“科学家们仍在研究”无症状传播的可能性。

In a statement to The New York Times, an agency spokeswoman acknowledged recent evidence that asymptomatic cases were possible but said that it was still uncertain whether people without symptoms could spread the virus and that more research was needed.

在给《纽约时报》的一份声明中,该机构的一名发言人承认,最近的证据表明无症状病例可能存在,但她表示,目前仍不确定无症状感染者是否会传播病毒,需要进行更多研究才能验证。

When the first few dozen cases of monkeypox emerged in Europe, spreading of the virus through sexual contact and genital lesions came as a surprise to many scientists. But it shouldn’t have.

欧洲最开始出现数十例猴痘病例的时候,病毒通过性接触传播及其引发的生殖器病变令许多科学家感到意外。但这应是意料之中的情况。

Nigerian researchers reported a similar pattern in 2017, when they documented 228 cases, many of them young men with genital ulcers. (The patients identified as heterosexual in a subsequent study, but Nigeria criminalizes same-sex behavior.)

2017年,尼日利亚研究人员就报告了类似的传播模式,当时他们记录了228例患者,其中许多人都是生殖器出现溃疡的年轻男性。(这些患者在随后的研究中被注明为异性恋,尼日利亚将同性性行为定为犯罪。)

Those cases were the first reported in Nigeria in 40 years, and the World Health Organization helped the country “mount the local response, with the goal to control spread,” said Fadela Chaib, a spokeswoman for the organization.

那是尼日利亚40年来报告的首批病例,世界卫生组织发言人法德拉·沙伊布表示,该机构帮助该国“采取了本土应对措施,以实现控制传播的目标”。

But the unusual symptoms of the patients went unnoticed. “If what is happening in Europe and the global North had not happened, I don’t think that paper would be discussed,” said Dr. Dimie Ogoina, who led a study describing the cases.

但患者的异常症状并未引起重视。“如果欧洲和北半球没有出现这些情况,我不认为那篇论文会引起什么讨论,”迪米·奥戈伊纳博士说,他领导了一项描述了这些病例的研究。

“We have this disease that’s more than 50 years old, and there’s a lot of things we still don’t know — and that’s because the condition has been largely restricted to Africa,” he said.

“这种疾病已有50多年的历史,但还有很多我们尚不了解的问题——因为这种疾病的传播主要局限于非洲,”他说。

In late May, Dr. Orkin contacted several international colleagues to put together what turned out to be the largest study of monkeypox. Hundreds of physicians from 16 countries eventually contributed information about the cases they were seeing.

5月下旬,奥金联系到数位国内外同仁,对猴痘进行了后来被证明是规模最大的研究。最终,有来自16个国家的数百名医生提供了他们所诊治的病例信息。

They changed the reporting forms as the disease came into sharper focus, adding the possibility of a single pox, lesions in the throat or rectum, and medical complications — features that were “not included in international case definitions of monkeypox,” Dr. Orkin said.

他们改变了病例报告的形式,更突出疾病症状,并增加了单一痘疹、喉咙或直肠病变以及并发症的可能性,奥金表示,这些特征此前都“不属于国际上对猴痘病例的定义”。

The resulting analysis of 528 patients was published in The New England Journal of Medicine on July 21. A few days later, Dr. Orkin alerted several national health agencies, knowing the findings should alter the case definitions that doctors consult when diagnosing patients.

对528名患者的结果分析发表在7月21日刊出的《新英格兰医学杂志》上。几天后,奥金通知了数家国家级卫生机构,他相信这些发现应该会改变医生在诊断患者时参考的病例定义。

Britain’s Health Security Agency and the European Centers for Disease Control both replied the same day. Britain added some of the new symptoms to its monkeypox case definition three days later. The European agency invited Dr. Orkin to present her findings.

英国卫生安全署和欧洲疾病预防控制中心在同一天做出了答复。英国三天后在猴痘病例定义中添加了其中一些新症状。欧洲疾控中心则邀请奥金陈述她的发现。

In an interview in late July, Dr. Orkin reflected that during pandemics, public health agencies are considered the experts, and officials educate doctors on the disease and its treatment. Yet it’s clinicians who see the symptoms firsthand.

在7月下旬的一次采访中,奥金表示,在疫情期间,公共卫生机构被当作专家,官员们会向医生科普疾病及其治疗办法。但亲眼目睹症状的人还是临床医生。

“It seems to me that consulting with clinicians in the field may have been helpful,” she said. National health agencies have been slow to understand the virus’s many manifestations in the current outbreak, she added.

“在我看来,咨询该领域的临床医生可能会有所帮助,”她说。她还表示,国家级卫生机构在此次疫情中对猴痘病毒多种表征的了解一直进展缓慢。

Dr. Orkin is president of the Medical Women’s Federation, past president of the British H.I.V. Association and a governing council member of the International AIDS Society. “I’ve got a loud voice,” she said, “and I’m still finding it difficult to get a response.”

作为现任英国女医师协会会长,奥金曾担任英国艾滋病毒协会会长兼国际艾滋病协会理事会成员。“我的嗓门是很大的,”她说,“但我依然很难得到回应。”

Senior members of the W.H.O. responded to Dr. Orkin on Aug. 2, asking to discuss the cases that she and her colleagues had described. The C.D.C. did not reply to Dr. Orkin but added rectal pain and bleeding, along with other new symptoms, to its guidance to clinicians on Aug. 5.

世卫组织高级成员在8月2日回复了奥金,要求讨论她和她的同事描述过的病例。美国疾控中心没有回复奥金,但在8月5日给临床医生的指导中增加了直肠疼痛和出血,以及其他新症状。

The new C.D.C. definition mentions lesions in the mouth but does not describe the range or importance of pox in the mouth, eyes and urethra. In its statement, the agency said it was aware of Dr. Orkin’s findings and had begun studies “that will help us better understand the range and importance of lesions at these and other bodily sites.”

美国疾控中心的新定义提到了口腔病变,但没有描述口腔、眼部和尿道出现痘疹的程度或严重性。该机构在声明中表示了解奥金的发现,并已着手进行研究,“将帮助我们更好的了解这些以及其他身体部位病变的程度和严重性。”

Based on reports that the virus persists in semen for weeks, Britain recommended that men who recover from monkeypox use condoms for 12 weeks after infection, a tacit acknowledgment that this may be a transmission route.

根据猴痘病毒可在精液中存留数周的报告,英国建议感染猴痘的男性在康复后12周内使用避孕套,这是对猴痘性传播途径的默认。

The C.D.C. has not gone along, saying that “researchers are working with our partners to learn if, and how frequently, the virus is being spread through contact with semen.”

美国疾控中心没有效仿,而是声称“研究人员正与我们的合作伙伴配合,了解病毒是否会通过精液接触传播以及传播的频率如何”。

The agency should advise men to wear condoms for a few weeks, as Britain has, Dr. Karan said. “We do not know how long people can transmit through semen,” he said. “I think they should communicate that clearly.”

卡兰表示,该机构应该像英国一样,建议男性多戴几周避孕套。“我们不知道人际之间精液传播的时效是多久,”他说。“我认为他们应该把这一点传达清楚。”

For patients, outdated case definitions and guidance can have serious implications. Cameron French, 30, was exposed to the virus on July 6. Two weeks later, he developed a sore throat, head and body aches, painful urination and three bumps — on his face, a thigh and an elbow.

对患者而言,滞后的病例定义和诊断指导可能会带来严重后果。30岁的卡梅伦·弗伦奇在7月6日接触到了猴痘病毒。两周后,他出现喉咙痛、头部和身体疼痛、尿痛的现象,且有三处肿包,分别在脸部、大腿和肘部。

Yet on his first visit to a clinic, on July 25, his doctor did not connect the symptoms. She told him the bump on his thigh was an ingrown hair and tested him for a urinary tract infection.

然而在他7月25日第一次就诊时,他的医生并没有将这些症状与猴痘联系起来。她告诉他,大腿上的肿包是毛发内生,并给他做了尿路感染检查。

He went back three days later. This time, the doctor agreed to test him for monkeypox. After he tested positive, he had to push once again, this time to get the antiviral tecovirimat.

三天后他又去就诊。这一次,医生同意给他做猴痘检测。在检查出阳性后,他不得不再次敦促医生,以便获得抗病毒药物特考韦瑞。

Mr. French said he was most frustrated by the lack of guidance on how to distinguish a potential new pox from a pimple so he could end his monthlong isolation. “That’s been a big ambiguous question mark,” he said. “That’s been hard.”

弗伦奇说,最让他感到沮丧的是没有指导说明应如何区分潜在新痘疹和面部丘疹,以便让他结束长达一个月的隔离。“这是一个很不明确的巨大问号,”他说。“真的让人很难受。”
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