[英中] 下一場大流行 NYTimes

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《下一場大流行比你想的要近》 - NYTimes.com OP-ED CONTRIBUTOR 紐時社論對頁專欄 The Next Pandemic: Not if, but When By DAVID QUAMMEN Published: May 9, 2013 BOZEMAN, Mont TERRIBLE new forms of infectious disease make headlines, but not at the start. Every pandemic begins small. Early indicators can be subtle and ambiguous. When the Next Big One arrives, spreading across oceans and continents like the sweep of nightfall, causing illness and fear, killing thousands or maybe millions of people, it will be signaled first by quiet, puzzling reports from faraway places — reports to which disease scientists and public health officials, but few of the rest of us, pay close attention. Such reports have been coming in recent months from two countries, China and Saudi Arabia. 嚇人的新興傳染病躋身頭版頭條時總不是在它的肇始。凡大流行皆有寒微出身。初始徵兆時常隱晦不明。在下一股惡勢力抬頭，席捲四野八方、海內天涯，如垂暮時分黑夜的邊界般掠席世界，使世人股慄膽寒，死者以萬計......發生之前，它多半只以低調、發生在遠方的謎樣案件報告昭示其降生。對這些難解的個案時刻掛心者，除了流病學家與公衛專家外，常人少有。然而近幾個月這樣的報告已然現身於中國與沙烏地阿拉伯。 You may have seen the news about H7N9, a new strain of avian flu claiming victims in Shanghai and other Chinese locales. Influenzas always draw notice, and always deserve it, because of their great potential to catch hold, spread fast, circle the world and kill lots of people. But even if you’ve been tracking that bird-flu story, you may not have noticed the little items about a “novel coronavirus” on the Arabian Peninsula. 也許你注意到H7N9新型禽流感在中國上海奪走幾條人命的消息。流感總引人注意－－它們應得的－－因為它們無匹的感染力、傳播速度、以及環遊世界廣發便當的能力。即使上述「鳥」事你聽過了，你八成不知道同時間在阿拉伯半島，一種「新型冠狀病毒」正橫空出世。 This came into view last September, when the Saudi Ministry of Health announced that such a virus — new to science and medicine — had been detected in three patients, two of whom had already died. By the end of the year, a total of nine cases had been confirmed, with five fatalities. As of Thursday, there have been 18 deaths, 33 cases total, including one patient now hospitalized in France after a trip to the United Arab Emirates. Those numbers are tiny by the standards of global pandemics, but here’s one that’ s huge: the case fatality rate is 55 percent. The thing seems to be almost as lethal as Ebola. 事情是2012年九月開始的，沙國衛生署公告該國三名病患帶有這種生醫科學界從未見過的新病毒，其中兩名患者死亡。2012年底增加為9例5死。直至今日(2013年5月9日星期四)已經33例18死，包括一例法國人自阿聯酋(UAE)返國後發病住院中。與正格的全球流行相比，這樣的案例數猶如星火。然而55%的[確診案例]死亡率使其危險性直追伊波拉病毒(*)。 (*譯注：星火可以燎原，故意翻的。Ebola近年在烏干達、金夏沙剛果、蘇丹的幾次流行，其案例死亡率(case fatality rate, CFR)介於四到八成之間，每次爆發CFR相差大可能因為屬於不同亞型。光看致死率可能會錯估疾病全貌，況且猶如霍亂、痢疾在先進國家或落後國家醫療資源可近性不同而有差別，大人或小孩間的致死率也有差別。除了致死率，另一評估疾病的危險性就是傳染力了，有用的指標是發生率(Incidence，但盛行率: Prevalence不是傳染力的指標)、傳染模式(空氣、飛沫、糞口、接觸、體液、昆蟲、禽鼠)、和流病模型中公衛專家致力於減少的「基本傳染數」(Basic Reproduction Number, 平均一個人能傳給多少人，>1則疾病成指數爆發，恆常居冠的麻疹病毒高達~15)。因此看到新聞標題如「超級淋病！傳染力如愛滋」->姚明臉。但要是看到標題寫「超級菜花，傳染力如麻疹」->塊陶啊兄弟。*) Coronaviruses are a genus of bugs that cause respiratory and gastrointestinal infections, sometimes mild and sometimes fierce, in humans, other mammals and birds. They became infamous by association in 2003 because the agent for severe acute respiratory syndrome, or SARS, is a coronavirus. That one emerged suddenly in southern China, passed from person to person and from Guangzhou to Hong Kong, then went swiftly onward by airplane to Toronto, Singapore and elsewhere. Eventually it sickened about 8,000 people, of whom nearly 10 percent died. If not for fast scientific work to identify the virus and rigorous public health measures to contain it, the total case count and death toll could have been much higher. 冠狀病毒是一類(*)感染呼吸道與/或腸胃道的壞東西，症狀輕重不一，宿主為鳥類與哺乳類－－含人類。冠狀病毒獲得狼藉聲名自然是因為2003年的SARS事件中元兇正是其家族成員SARS-CoV。SARS-CoV突然在中國南部冒出來，經過人到人接力傳播，由廣州到了香港，在香港坐上飛機到了多倫多、新加坡等地 [連結1] ......最終它傳染了8000餘人，其中一成沒能挺下去。倘若全球生醫科學界未及時辨認出病原，或是各國衛生機關未釜底抽薪控制病毒傳播[連結2]，SARS-CoV 本有進一步擴大事態的可能。 (*譯註: 原文中genus是屬，但病毒並不一定完整的被區分成界門綱目科屬種。一般是依照Baltimore classification，根據病毒複製周期分為七大組(Groups) ，底下依照宿主、形態、分子生物相似性等方法分為各科(family)。但地球生物圈以內的病毒種類幾乎數不盡，細分下去往往困難，即使建立了演化親疏關係的系統發生樹(phylogenetic tree) ，樹中的分群(cluster)與分支也無暇命名多半只編號，有名字的屬(genus)不多。另外病毒的領域中總有些破格的傢伙陸續被發現－－總之有句不知哪看來的話所言甚是：「分類是一種信念」，是種是人皆希望脈絡齊整分明的習性，然而自然界永遠比人有想像力。*) [1]後來釐清出當年使SARS揚名立萬的主要傳染順序: 科學松鼠會 - SARS病毒的2003之旅：動物、酒店與飛機 http://songshuhui.net/archives/79557 [2]衛生機關「控制」病毒傳播的方法也有這般九流彆腳的: 和平醫院隔離日記Day1~10 小兒科醫師林秉鴻 [ptt.cc / NTUHospital / z-12-4-1-1] One authority at the Centers for Disease Control and Prevention, an expert on nasty viruses, told me that the SARS outbreak was the scariest such episode he ’d ever seen. That cautionary experience is one reason this novel coronavirus in the Middle East has attracted such concern. 一位[美國]疾病控制與預防中心(CDC)的權威專家告知筆者，即使他已經和各種窮凶極惡的病毒在實驗室中打過交道，當年的SARS大流行依然穩坐他經歷過最「挫」最恐怖的情境之首位。有SARS為戒，這次中東新型冠狀病毒得事件才會得到關切如許。 Another reason is that coronaviruses as a group are very changeable, very protean, because of their high rates of mutation and their proclivity for recombination: when the viruses replicate, their genetic material is continually being inaccurately copied — and when two virus strains infect a single host cell, it is often intermixed. Such rich genetic variation gives them what one expert has called an “intrinsic evolvability,” a capacity to adapt quickly to new circumstances within new hosts. 額外的理由是，冠狀病毒(*屬於單股RNA病毒*)是如此捉摸不定的善變：它有很高的突變率與重組率。病毒複製經常出錯因而得到新的遺傳密碼，而感染同一細胞的兩株病毒易於互相嵌合、使其基因重組洗牌。這樣豐沛的可能性讓專家稱冠狀病毒具有「固有演化潛力」－－能夠快速的適應新環境、新宿主。 But hold on. I said that the SARS virus “emerged” in southern China, and that raises the question: emerged from where? Every new disease outbreak starts as a mystery, and among the first things to be solved is the question of source. 等一下。筆者剛才提到SARS-CoV在「中國南部」崛起，這來由能不能再更精確點？所有傳染病的起源都是場探案蒐秘，而首先必須被解答者：起源何處。 In most cases, the answer is wildlife. Sixty percent of our infectious diseases fall within this category, caused by viruses or other microbes known as zoonoses. A zoonosis is an animal infection transmissible to humans. Another bit of special lingo: reservoir host. That’s the animal species in which the zoonotic bug resides endemically, inconspicuously, over time. Some unsuspecting person comes in contact with an infected monkey, ape, rodent or wild goose — or maybe just with a domestic duck that has fed around the same pond as the wild goose — and a virus achieves transcendence, passing from one species of host into another. The disease experts call that event a spillover. 曰「野生動物」猜中者十有八九。事實上60%的傳染性疾病皆如此，這些微生物 (*不限於病毒，細菌、原蟲、真菌亦可*)是所謂「人畜共通傳染病」(zoonosis，複數: -ses)，顧名思義就是主要由動物傳染到人類身上的疾病。再奉上一個專業術語叫做「病原儲庫」(reservoir host, 讀做: 雷蛇哇厚思t)，意思是該病原在人類以外也可傳染動物，並且在動物群體中長治久安，低調不鬧事不發病地待著，或是發病但不大致命所以穩定地傳來傳去而一直存在 (endemic)。因此當沒戒心的人類與該動物接觸－－無論是帶有病原的猴子、猩猩、鼠類、野鳥，或是與野鳥互動過而染菌的家禽－－萬一病原群體裡適應新環境的精英份子成功完成跨物種感染，疾病專家稱之為「疾病溢流」(spillover)。 (*譯註: 讀者可能想問病原菌待得好好的幹嘛跨物種，是因為病毒喜歡嗎？不，這現象生態學上的解釋是，一種病原跨物種相當於發現可以殖民的新大陸－－術語叫做新的生態區位(ecological niche, 可居住繁殖生聚教訓的地點)－－新的空間、資源與奴隸是拉力，而舊生態區位當中過於擁擠造成種間競爭空間與資源是為通勤族、移民潮與衛星城市 ......不不，是推力。大航海時代，歐洲探險家驚訝的發現太平洋上所有能維生的島嶼全被南島民族殖民過了，如果人類[之於環境]是種疾病，人類會是首屈一指的生態區位的跳躍與存活專家*) Researchers have established that the SARS virus emerged from a bat. The virus may have passed through an intermediate species — another animal, perhaps infected by cage-to-cage contact in one of the crowded live-animal markets of the region — before getting into a person. And while SARS hasn’t recurred, we can assume that the virus still abides in southern China within its reservoir hosts: one or more kinds of bat. 研究者千辛萬苦確立的共識：SARS-CoV最初來自蝙蝠。也許中間還有一種物種作為跳板，最可能是地區過於密集飼養的家畜與家禽家畜市場上的交互傳染，最終跳到人類身上。雖然SARS消聲匿跡了十年，然而我們不能排除該病毒[或其親戚] 仍然潛伏在中國南部它的天然宿主身上：一種或數種蝙蝠。 (*譯註:Natural host是病原體能感染繁殖傳播，在其身上完成整個生活史的動物，可以包含人。Reservoir host特指排除掉人類的其餘natural host。如果某病原的natural host主要是動物叫做zoonotic，偶爾傳給人；反之如果主要宿主是人類叫做 anthroponotic，偶爾傳給動物。　正如有的動物病原不會傳給人，有的疾病也是人類特有，就是natural host={人}, reservoir host={}，像皰疹病毒、體蝨、蟯蟲、麻疹、幽門螺旋桿菌。有個通則是這類跟人類一起共演化了千年萬年的病原體感染力都很高、但致死率都很低。想想為啥？科學家還能把這些共演化的病原體當成分子時鐘使用，標記出人類走出非洲的遷徙歷史路線！*) Bats, though wondrous and necessary animals, do seem to be disproportionately implicated as reservoir hosts of new zoonotic viruses: Marburg, Hendra, Nipah, Menangle and others. Bats gather in huge, sociable aggregations and have long life spans, circumstances that may be especially hospitable to viruses. And they fly. Traveling nightly to feed, shifting occasionally from one communal roost to another, they carry their infections widely and spread them to one another. 蝙蝠本身是種棒呆了的自然生物奇觀，也是生態系中的一個必須環結。但蝙蝠似乎在近年不成比例地涉案了太多種新興人畜共通傳染病，幾乎不成比例。馬堡病毒、 Hendra病毒、立百病毒、Menangle病毒......等等(*後三者親緣接近，同被分到 paramyxoviridae下的Henipavirus屬。曾經在1994-2006年在澳洲到東南-南亞有過若干次爆發*)。蝙蝠的特性是一大群集住在一起，有個體間互動，以及合適長短的壽命，也許這些條件給了各種病毒友善的居住環境。最重要是蝙蝠會飛，晝伏夜出覓食並且不時遷徙棲居處，將病毒在種群間傳來傳去無遠弗屆。 (*跟人類跟很久的病原體只是想混口飯吃存活繁衍下去，會重病在還沒傳播前就把人類宿主殺死的菌株是不被演化青睞的，過於猛烈的致病基因早就在族群中被壓抑下去了。與傳染力有關的基因對病菌的生存有益，可以一直改良所以一般來講傳染力都很有效率幾乎達到神乎奇技的專業狀態。這些專一性可以任生物學家拿來做為研究的工具，永遠要跟自然學習！然而新興傳染病還沒有達到這種停火協議般的平衡狀態，常常不知好歹的猛爆一陣疫情屍橫遍野但傳染鏈因此中斷，Bad Ending只好砍掉重練*) As for the novel coronavirus in Saudi Arabia, its reservoir host is still undiscovered. But you can be confident that scientific sleuths are on the case and that they will look closely at Arabian bats, including those that visit the productive date-palm groves at the oases of Al Ahsa, near the Persian Gulf. 至於出現在沙烏地阿拉伯的新型冠狀病毒，其宿主動物病毒庫尚未被確定。但是諸位讀者莫驚恐，滿地找線索的科學偵探們正著手解這個謎，他們尤其會緊盯著阿拉伯半島的蝙蝠，尤其是固定會到波斯灣沿岸Al Ahsa綠洲上結實纍纍棗椰樹叢拜訪的那些嬌客們。 What can we do? The first obligation is informed awareness. Early reports arrive from afar, seeming exotic and peripheral, but don’t be fooled. One emergent virus, sooner or later, will be the Next Big One. It may show up first in China, in Congo or Bangladesh, or maybe on the Arabian Peninsula; but it will globalize. Most people on earth nowadays live within 24 hours’ travel time of Saudi Arabia. And in October, when millions of people journey to Mecca for the hajj, the Muslim pilgrimage, the lines of connections among humans everywhere will be that much shorter. 一般讀者能做些什麼？首先是對海內外消息的警覺留意。早期的報導來自遠方，既不著邊際又好似與當下此地毫無關聯－－但別被唬了。某個正在崛起的「下一個龐然大物」病毒，可能現身於中國、剛果、孟加拉、或阿拉伯半島，但終究會環遊全球。由沙烏地阿拉伯出發在24小時內可以到達地球上幾乎所有地方。然後在十月，全世界最大的人流，百萬計的穆斯林將湧進聖城麥加進行朝聖(The Hajj)，因此連繫世界的線將緊緊地被拽在一起。 (*the next big one原來是在形容大地震，知道不遠的未來它一定會發生，只是不知時間是遠是近，像加州人挫咧等的聖安地列斯斷層大地震，或是會將東京市夷平淹沒再掩埋的預想東海大地震*) (*幹，我好挫喔，可以假裝不知道嗎。the Hajj之於新冠狀病毒，正猶如中國五一連假之於H7H9－－假設已經人傳人幾乎是必然爆發大流行的契機。不過話說回來到現在還沒爆，幾乎肯定H7N9還沒有人傳人，可喜可賀*) We can’t detach ourselves from emerging pathogens either by distance or lack of interest. The planet is too small. We’re like the light heavyweight boxer Billy Conn, stepping into the ring with Joe Louis in 1946: we can run, but we can’t hide. 距離或不關心已經無法將新興傳染病從我們身邊隔開，地球已經變得太小。好像重量級拳擊手的拳賽，踏進了擂台後，你可以閃躲但總是躲不了一輩子 David Quammen, a contributing writer for National Geographic, is the author, most recently, of “Spillover: Animal Infections and the Next Human Pandemic. ” 原作者大衛夸門，國家地理雜誌供稿人，為最近＜疾病溢流：動物傳染病與下個人類大流行＞之作者 -- ※ 發信站: 批踢踢實業坊(ptt.cc) ◆ From: 140.112.213.88