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非洲的黄热病:对公共卫生的影响及21世纪的防控前景

Yellow fever in Africa: public health impact and prospects for control in the 21st century.

作者信息

Tomori Oyewale

机构信息

WHO Region, Belvedere, Harare, Zimbabwe.

出版信息

Biomedica. 2002 Jun;22(2):178-210.

Abstract

In the last two decades, yellow fever re-emerged with vehemence to constitute a major public health problem in Africa. The disease has brought untold hardship and indescribable misery among different populations in Africa. It is one of Africa's stumbling blocks to economic and social development. Despite landmark achievements made in the understanding of the epidemiology of yellow fever disease and the availability of a safe and efficacious vaccine, yellow fever remains a major public health problem in both Africa and America where the disease affects annually an estimated 200,000 persons causing an estimated 30,000 deaths. Africa contributes more than 90% of global yellow fever morbidity and mortality. Apart from the severity in morbidity and mortality, which are grossly under reported, successive outbreaks of yellow fever and control measures have disrupted existing health care delivery services, overstretched scarce internal resources, fatigued donor assistance and resulted in gross wastage of vaccines. Recent epidemics of yellow fever in Africa have affected predominantly children under the age of fifteen years. Yellow fever disease can be easily controlled. Two examples from Africa suffice to illustrate this point. Between 1939 and 1952, yellow fever virtually disappeared in parts of Africa, where a systematic mass vaccination programme was in place. More recently, following the 1978-1979 yellow fever epidemic in the Gambia, a mass yellow fever vaccination programme was carried out, with a 97% coverage of the population over 6 months of age. Subsequently, yellow fever vaccination was added to the EPI Programme. The Gambia has since then maintained a coverage of over 80%, without a reported case of yellow fever, despite being surrounded by Senegal which experienced yellow fever outbreaks in 1995 and 1996. The resurgence of yellow fever in Africa and failure to control the disease has resulted from a combination of several factors, including: 1) collapse of health care delivery systems; 2) lack of appreciation of the full impact of yellow fever disease on the social and economic development of the affected communities; 3) insufficient political commitment to yellow fever control by governments of endemic countries; 4) poor or inadequate disease surveillance; 5) inappropriate disease control measures, and 6) preventable poverty coupled with misplaced priorities in resource allocation. Yellow fever can be controlled in Africa within the next 10 years, if African governments seize the initiative for yellow fever control by declaring an uncompromising resolve to control the disease, the governments back up their resolve with an unrelenting commitment and unwavering political will through adequate budgetary allocations for yellow fever control activities, and international organisations, such as WHO, UNICEF, GAVI, etc., provide support and technical leadership and guidance to yellow fever at risk countries. Over a ten-year period, of stage-by-stage mass yellow fever vaccination campaigns, integrated with successful routine immunisation, Africa can bring yellow fever under control. Subsequently, for yellow fever to cease being a public health problem, Africa must maintain at least an annual 80% yellow fever vaccine coverage of children under the age of 1 year, and sustain a reliable disease surveillance system with a responsive disease control programme. This can be achieved at an affordable annual expenditure of less than US$1.00 per person per year, with a reordering of priorities.

摘要

在过去二十年中,黄热病猛烈卷土重来,成为非洲一个主要的公共卫生问题。该疾病给非洲不同人群带来了难以言表的艰难困苦和无法形容的痛苦。它是非洲经济和社会发展的绊脚石之一。尽管在黄热病流行病学认识方面取得了里程碑式的成就,并且有安全有效的疫苗可供使用,但黄热病在非洲和美洲仍然是一个主要的公共卫生问题,在这些地区,该疾病每年估计影响20万人,导致约3万例死亡。非洲占全球黄热病发病率和死亡率的90%以上。除了发病率和死亡率严重且严重漏报外,黄热病的连续爆发和控制措施扰乱了现有的医疗服务提供体系,过度消耗了稀缺的国内资源,使捐助援助疲惫不堪,并导致疫苗的大量浪费。非洲最近的黄热病疫情主要影响15岁以下的儿童。黄热病很容易得到控制。来自非洲的两个例子足以说明这一点。1939年至1952年期间,非洲部分地区的黄热病实际上消失了,因为当时实施了系统的大规模疫苗接种计划。最近,在冈比亚1978 - 1979年黄热病疫情之后,开展了大规模黄热病疫苗接种计划,6个月以上人口的接种覆盖率达到了97%。随后,黄热病疫苗接种被纳入扩大免疫规划(EPI)。从那时起,冈比亚的接种覆盖率一直保持在80%以上,没有报告过黄热病病例,尽管其被1995年和1996年爆发黄热病的塞内加尔包围。非洲黄热病的死灰复燃以及未能控制该疾病是由多种因素共同导致的,包括:1)医疗服务提供体系的崩溃;2)对黄热病对受影响社区社会和经济发展的全面影响认识不足;3)流行国家政府对黄热病控制的政治承诺不足;4)疾病监测薄弱或不足;5)疾病控制措施不当;6)可预防的贫困以及资源分配的优先次序错位。如果非洲各国政府抓住控制黄热病的主动权,宣布毫不妥协地决心控制该疾病,通过为黄热病控制活动提供充足的预算拨款来以坚定的承诺和坚定不移的政治意愿来支持其决心,并且世界卫生组织(WHO)、联合国儿童基金会(UNICEF)、全球疫苗免疫联盟(GAVI)等国际组织向有黄热病风险的国家提供支持以及技术领导和指导,那么在未来十年内非洲可以控制黄热病。在十年期间分阶段开展大规模黄热病疫苗接种运动,并与成功的常规免疫相结合,非洲能够控制黄热病。随后,为了使黄热病不再成为公共卫生问题,非洲必须至少保持每年对1岁以下儿童80%的黄热病疫苗接种覆盖率,并维持一个可靠的疾病监测系统以及一个反应迅速的疾病控制计划。通过重新调整优先次序,每年人均花费不到1美元就可以实现这一目标。

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