《下一场大流行比你想的要近》 - NYTimes.com OP-ED CONTRIBUTOR 纽时社论对页专栏 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. 吓人的新兴传染病跻身头版头条时总不是在它的肇始。凡大流行皆有寒微出身。 初始徵兆时常隐晦不明。在下一股恶势力抬头，席卷四野八方、海内天涯，如垂 暮时分黑夜的边界般掠席世界，使世人股栗胆寒，死者以万计......发生之前， 它多半只以低调、发生在远方的谜样案件报告昭示其降生。对这些难解的个案时 刻挂心者，除了流病学家与公卫专家外，常人少有。然而近几个月这样的报告已 然现身於中国与沙乌地阿拉伯。 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. 也许你注意到H7N9新型禽流感在中国上海夺走几条人命的消息。流感总引人注意 －－它们应得的－－因为它们无匹的感染力、传播速度、以及环游世界广发便当 的能力。即使上述「鸟」事你听过了，你八成不知道同时间在阿拉伯半岛，一种 「新型冠状病毒」正横空出世。 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年九月开始的，沙国卫生署公告该国三名病患带有这种生医科学界从未 见过的新病毒，其中两名患者死亡。2012年底增加为9例5死。直至今日(2013年5月9日 星期四)已经33例18死，包括一例法国人自阿联酋(UAE)返国後发病住院中。与正格 的全球流行相比，这样的案例数犹如星火。然而55%的[确诊案例]死亡率使其危险 性直追伊波拉病毒(*)。 (*译注：星火可以燎原，故意翻的。Ebola近年在乌干达、金夏沙刚果、苏丹的几次流 行，其案例死亡率(case fatality rate, CFR)介於四到八成之间，每次爆发CFR相差大可 能因为属於不同亚型。 光看致死率可能会错估疾病全貌，况且犹如霍乱、痢疾在先进国家或落後国家医疗资源可 近性不同而有差别，大人或小孩间的致死率也有差别。除了致死率，另一评估疾病的危险 性就是传染力了，有用的指标是发生率(Incidence，但盛行率: Prevalence不是传染力的 指标)、传染模式(空气、飞沫、粪口、接触、体液、昆虫、禽鼠)、和流病模型中公卫专 家致力於减少的「基本传染数」(Basic Reproduction Number, 平均一个人能传给多少人 ，>1则疾病成指数爆发，恒常居冠的麻疹病毒高达~15)。 因此看到新闻标题如「超级淋病！传染力如爱滋」->姚明脸。但要是看到标题写「超级菜 花，传染力如麻疹」->块陶啊兄弟。*) 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. 冠状病毒是一类(*)感染呼吸道与/或肠胃道的坏东西，症状轻重不一，宿主为 鸟类与哺乳类－－含人类。冠状病毒获得狼藉声名自然是因为2003年的SARS事 件中元凶正是其家族成员SARS-CoV。SARS-CoV突然在中国南部冒出来，经过人 到人接力传播，由广州到了香港，在香港坐上飞机到了多伦多、新加坡等地 [连结1] ......最终它传染了8000余人，其中一成没能挺下去。倘若全球生医科学界未 及时辨认出病原，或是各国卫生机关未釜底抽薪控制病毒传播[连结2]，SARS-CoV 本有进一步扩大事态的可能。 (*译注: 原文中genus是属，但病毒并不一定完整的被区分成界门纲目科属种。一般是依 照Baltimore classification，根据病毒复制周期分为七大组(Groups) ，底下依照宿主 、形态、分子生物相似性等方法分为各科(family)。但地球生物圈以内的病毒种类几乎数 不尽，细分下去往往困难，即使建立了演化亲疏关系的系统发生树(phylogenetic tree) ，树中的分群(cluster)与分支也无暇命名多半只编号，有名字的属(genus)不多。 另外病毒的领域中总有些破格的家伙陆续被发现－－总之有句不知哪看来的话所言甚是： 「分类是一种信念」，是种是人皆希望脉络齐整分明的习性，然而自然界永远比人有想像 力。*) [1]後来厘清出当年使SARS扬名立万的主要传染顺序: 科学松鼠会 - SARS病毒的2003之旅：动物、酒店与飞机 http://songshuhui.net/archives/79557 [2]卫生机关「控制」病毒传播的方法也有这般九流别脚的: 和平医院隔离日记Day1~10 小儿科医师林秉鸿 [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[美国]疾病控制与预防中心(CDC)的权威专家告知笔者，即使他已经和各种 穷凶极恶的病毒在实验室中打过交道，当年的SARS大流行依然稳坐他经历过最 「挫」最恐怖的情境之首位。有SARS为戒，这次中东新型冠状病毒得事件才会得 到关切如许。 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. 额外的理由是，冠状病毒(*属於单股RNA病毒*)是如此捉摸不定的善变：它有很 高的突变率与重组率。病毒复制经常出错因而得到新的遗传密码，而感染同一细胞 的两株病毒易於互相嵌合、使其基因重组洗牌。这样丰沛的可能性让专家称冠状 病毒具有「固有演化潜力」－－能够快速的适应新环境、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。笔者刚才提到SARS-CoV在「中国南部」崛起，这来由能不能再更精确点？ 所有传染病的起源都是场探案蒐秘，而首先必须被解答者：起源何处。 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「野生动物」猜中者十有八九。事实上60%的传染性疾病皆如此，这些微生物 (*不限於病毒，细菌、原虫、真菌亦可*)是所谓「人畜共通传染病」(zoonosis， 复数: -ses)，顾名思义就是主要由动物传染到人类身上的疾病。再奉上一个专业 术语叫做「病原储库」(reservoir host, 读做: 雷蛇哇厚思t)，意思是该病原在 人类以外也可传染动物，并且在动物群体中长治久安，低调不闹事不发病地待着， 或是发病但不大致命所以稳定地传来传去而一直存在 (endemic)。因此当没戒心的 人类与该动物接触－－无论是带有病原的猴子、猩猩、鼠类、野鸟，或是与野鸟互 动过而染菌的家禽－－万一病原群体里适应新环境的精英份子成功完成跨物种感染 ，疾病专家称之为「疾病溢流」(spillover)。 (*译注: 读者可能想问病原菌待得好好的干嘛跨物种，是因为病毒喜欢吗？不，这现象生 态学上的解释是，一种病原跨物种相当於发现可以殖民的新大陆－－术语叫做新的生态区 位(ecological niche, 可居住繁殖生聚教训的地点)－－新的空间、资源与奴隶是拉力， 而旧生态区位当中过於拥挤造成种间竞争空间与资源是为通勤族、移民潮与卫星城市 ......不不，是推力。大航海时代，欧洲探险家惊讶的发现太平洋上所有能维生的岛屿全 被南岛民族殖民过了，如果人类[之於环境]是种疾病，人类会是首屈一指的生态区位的跳 跃与存活专家*) 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. 研究者千辛万苦确立的共识：SARS-CoV最初来自蝙蝠。也许中间还有一种物种作 为跳板，最可能是地区过於密集饲养的家畜与家禽家畜市场上的交互传染，最终 跳到人类身上。虽然SARS消声匿迹了十年，然而我们不能排除该病毒[或其亲戚] 仍然潜伏在中国南部它的天然宿主身上：一种或数种蝙蝠。 (*译注:Natural host是病原体能感染繁殖传播，在其身上完成整个生活史的动物，可以 包含人。Reservoir host特指排除掉人类的其余natural host。如果某病原的natural host主要是动物叫做zoonotic，偶尔传给人；反之如果主要宿主是人类叫做 anthroponotic，偶尔传给动物。 　正如有的动物病原不会传给人，有的疾病也是人类特有，就是natural host={人}, reservoir host={}，像疱疹病毒、体蝨、蛲虫、麻疹、幽门螺旋杆菌。有个通则是这 类跟人类一起共演化了千年万年的病原体感染力都很高、但致死率都很低。想想为啥？ 科学家还能把这些共演化的病原体当成分子时钟使用，标记出人类走出非洲的迁徙历史路 线！*) 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. 蝙蝠本身是种棒呆了的自然生物奇观，也是生态系中的一个必须环结。但蝙蝠似 乎在近年不成比例地涉案了太多种新兴人畜共通传染病，几乎不成比例。马堡病毒、 Hendra病毒、立百病毒、Menangle病毒......等等(*後三者亲缘接近，同被分到 paramyxoviridae下的Henipavirus属。曾经在1994-2006年在澳洲到东南-南亚有 过若干次爆发*)。蝙蝠的特性是一大群集住在一起，有个体间互动，以及合适长 短的寿命，也许这些条件给了各种病毒友善的居住环境。最重要是蝙蝠会飞，昼 伏夜出觅食并且不时迁徙栖居处，将病毒在种群间传来传去无远弗届。 (*跟人类跟很久的病原体只是想混口饭吃存活繁衍下去，会重病在还没传播前就把人类宿 主杀死的菌株是不被演化青睐的，过於猛烈的致病基因早就在族群中被压抑下去了。与传 染力有关的基因对病菌的生存有益，可以一直改良所以一般来讲传染力都很有效率几乎达 到神乎奇技的专业状态。这些专一性可以任生物学家拿来做为研究的工具，永远要跟自然 学习！然而新兴传染病还没有达到这种停火协议般的平衡状态，常常不知好歹的猛爆一阵 疫情屍横遍野但传染链因此中断，Bad Ending只好砍掉重练*) 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. 至於出现在沙乌地阿拉伯的新型冠状病毒，其宿主动物病毒库尚未被确定。但是诸 位读者莫惊恐，满地找线索的科学侦探们正着手解这个谜，他们尤其会紧盯着阿拉 伯半岛的蝙蝠，尤其是固定会到波斯湾沿岸Al Ahsa绿洲上结实累累枣椰树丛拜访的 那些娇客们。 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. 一般读者能做些什麽？首先是对海内外消息的警觉留意。早期的报导来自远方，既 不着边际又好似与当下此地毫无关联－－但别被唬了。某个正在崛起的「下一个庞 然大物」病毒，可能现身於中国、刚果、孟加拉、或阿拉伯半岛，但终究会环游全 球。由沙乌地阿拉伯出发在24小时内可以到达地球上几乎所有地方。然後在十月， 全世界最大的人流，百万计的穆斯林将涌进圣城麦加进行朝圣(The Hajj)，因此连 系世界的线将紧紧地被拽在一起。 (*the next big one原来是在形容大地震，知道不远的未来它一定会发生，只是不知时间 是远是近，像加州人挫咧等的圣安地列斯断层大地震，或是会将东京市夷平淹没再掩埋的 预想东海大地震*) (*干，我好挫喔，可以假装不知道吗。the Hajj之於新冠状病毒，正犹如中国五一连 假之於H7H9－－假设已经人传人几乎是必然爆发大流行的契机。不过话说回来到现在还没 爆，几乎肯定H7N9还没有人传人，可喜可贺*) 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. 距离或不关心已经无法将新兴传染病从我们身边隔开，地球已经变得太小。好像 重量级拳击手的拳赛，踏进了擂台後，你可以闪躲但总是躲不了一辈子 David Quammen, a contributing writer for National Geographic, is the author, most recently, of “Spillover: Animal Infections and the Next Human Pandemic. ” 原作者大卫夸门，国家地理杂志供稿人，为最近＜疾病溢流：动物传染病与下个人 类大流行＞之作者 --

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