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Eta statya ob infekcionnom zabolevanii o pandemii vyzvannoj zabolevaniem sm Pandemiya COVID 19 Zapros kovid perenapravlyaetsya syuda sm takzhe drugie znacheniya COVID 19 abbr ot angl COronaVIrus Disease 2019 koronavi rusnaya infe kciya 2019 goda rus kovi d sm Terminologiya ranee koronavirusnaya infekciya 2019 nCoV potencialno tyazhyolaya ostraya respiratornaya infekciya vyzyvaemaya koronavirusom SARS CoV 2 2019 nCoV Predstavlyaet soboj opasnoe zabolevanie kotoroe mozhet protekat kak v forme ostroj respiratornoj virusnoj infekcii lyogkogo techeniya tak i v tyazhyoloj forme K naibolee rasprostranyonnym simptomam zabolevaniya otnosyatsya povyshennaya temperatura tela utomlyaemost i suhoj kashel Virus sposoben porazhat razlichnye organy cherez pryamoe inficirovanie ili posredstvom immunnogo otveta organizma Naibolee chastym oslozhneniem zabolevaniya yavlyaetsya virusnaya pnevmoniya sposobnaya privodit k ostromu respiratornomu distress sindromu i posleduyushej ostroj dyhatelnoj nedostatochnosti pri kotoryh chashe vsego neobhodimy kislorodnaya terapiya i respiratornaya podderzhka V chislo oslozhnenij vhodyat poliorgannaya nedostatochnost septicheskij shok i venoznaya tromboemboliya COVID 19Peredacha i zhiznennyj cikl virusa SARS CoV 2 vyzyvayushego infekciyu COVID 19Sinonimy Koronavirusnaya infekciya COVID 19 koronavirusnaya infekciya 2019 nCoV kovid 19 kovidSpecialnost infektologiya d pulmonologiya virusologiya epidemiologiya i neotlozhnaya medicinskaya pomoshSimptomy kashel lihoradka dyhatelnaya nedostatochnost golovnaya bol mialgiya pereutomlenie krovoharkane diareya odyshka limfopeniya vd anemiya anosmiya agevziya d gipoksiya oznob zalozhennost nosa anoreksiya toshnota konyunktivit boli v oblasti zhivota i taza virusnaya pnevmoniya povrezhdenie mozga delirij psihoz encefalit Enantema emocionalnoe vygoranie i erektilnaya disfunkciyaPrichiny SRAS CoV 2Metod diagnostiki PCR s obratnoj transkripciej immunofermentnyj analiz CT polimeraznaya cepnaya reakciya i Bystryj test na antigen COVID 19Lechenie simptomaticheskoe lechenie d protivovirusnyj preparat oksigenoterapiya immunoterapiya immunoglobuliny dlya vnutrivennogo vvedeniya immunodepressant imunnaya syvorotka vd i treatment of COVID 19 vd Lekarstvo nirmatrelvir ritonavir vd Remdesivir Molnupiravir Favipiravir ruxolitinib vd kolhicin fluvoksamin REGN COV2 infliksimab orencia vd cenicriviroc vd tofacitinib Lenzilumab vd sargramostim vd mavrilimumab vd otilimab vd tradipitant vd aprepitant vd remestemcel L vd ibudilast vd apremilast ifenprodil vd ekulizumab ravulizumab vd selinexor vd prazozin losmapimod vd leronlimab vd nangibotide vd piclidenoson vd fenretinide vd Ebselen Fostamatinib vadadustat vd lanadelumab vd zilucoplan vd apabetalone vd Bucillamine vd Enisamiya jodid i deuremidevir vd Rasprostranyaetsya vozdushno kapelnym putyom cherez vdyhanie raspylyonnyh v vozduhe pri kashle chihanii ili razgovore kapel s virusom a takzhe cherez popadanie virusa na poverhnosti s posleduyushim zaneseniem v glaza nos ili rot Osnovnym sredstvom predotvrasheniya rasprostraneniya infekcii yavlyayutsya maski odnako oni dolzhny primenyatsya vmeste s kompleksom drugih mer profilaktiki vklyuchaya soblyudenie bezopasnoj distancii i izbeganie prebyvaniya v zamknutyh prostranstvah s bolshim kolichestvom lyudej K chislu effektivnyh mer profilaktiki otnosyatsya chastoe mytyo ruk i soblyudenie pravil respiratornoj gigieny Vakcinaciya yavlyaetsya bezopasnym i effektivnym sposobom snizheniya riskov smerti ot zabolevaniya tyazhyologo techeniya simptomaticheskih sluchaev i vozniknoveniya samoj infekcii Vakciny yavlyayutsya vazhnejshim novym sredstvom borby s zabolevaniem no prohozhdenie vakcinacii ne oznachaet chto mozhno prenebregat standartnymi merami profilaktiki poskolku vakcinaciya v pervuyu ochered napravlena na zashitu ot zabolevaniya a ne ot infekcii Posle vakcinacii obychno mogut poyavitsya kratkovremennye lyogkie pobochnye effekty sredi kotoryh golovnye boli boli v myshcah oznob i povyshenie temperatury U bolshinstva zarazivshihsya infekciya protekaet v lyogkoj forme ili bessimptomno Primerno v 80 kakoe libo specificheskoe lechenie ne trebuetsya a vyzdorovlenie proishodit samo po sebe Primerno v 15 sluchaev zabolevanie protekaet v tyazhyoloj forme s neobhodimostyu primeneniya kislorodnoj terapii eshyo v 5 sostoyanie bolnyh kriticheskoe Rannie dannye pokazyvayut chto omikron shtamm vyzyvaet menee tyazhyoluyu infekciyu nezheli predydushie varianty V redkih sluchayah porazhenie virusom detej i podrostkov predpolozhitelno mozhet privodit k razvitiyu vospalitelnogo sindroma Takzhe vozmozhny dolgosrochnye posledstviya nazyvaemye postkovidnym sindromom Tyazhyolye formy bolezni s bolshej veroyatnostyu mogut razvitsya u pozhilyh lyudej i u lyudej s opredelyonnymi soputstvuyushimi zabolevaniyami vklyuchayushimi astmu diabet i serdechnye zabolevaniya Vysokaya smertnost ot zabolevaniya mozhet obyasnyatsya tem chto ono mozhet porazhat raznye organy vklyuchaya lyogkie serdce pochki i pechen po etoj zhe prichine mozhet okazatsya neeffektivnym lechenie V tyazhyolyh ili kriticheskih sluchayah Vsemirnaya organizaciya zdravoohraneniya VOZ rekomenduet primenyat kortikosteroidy i baricitinib ingibitor yanus kinaz V tyazhyolyh sluchayah takzhe primenyayutsya sredstva dlya podderzhaniya funkcij zhiznenno vazhnyh organov SimptomySimptomy COVID 19 Naibolee rasprostranyonnymi simptomami yavlyayutsya lihoradka suhoj kashel ustalost poterya vkusa ili obonyaniya Menee chasto vstrechayutsya lomota v tele bol v gorle diareya konyunktivit golovnaya bol kozhnaya syp ili izmenenie cveta palcev ruk ili nog Poterya obonyaniya yavlyaetsya vysoko specifichnym simptomom i mozhet nablyudatsya bez soputstvuyushih lihoradki ili kashlya Mediannaya prodolzhitelnost poteri obonyaniya ili vkusa sostavlyaet primerno 8 dnej Soglasno VOZ opasnymi simptomami pri kotoryh neobhodima medicinskaya pomosh yavlyayutsya odyshka ili zatrudnyonnoe dyhanie boli v grudi ili oshushenie eyo sdavlivaniya poterya vozmozhnosti dvigatsya ili razgovarivat EpidemiologiyaOsnovnaya statya Pandemiya COVID 19 Sm takzhe Pandemiya COVID 19 Rasprostranenie po stranam i territoriyam Sglazhivanie krivoj zabolevaemosti za schyot zamedleniya skorosti rasprostraneniya infekcii pozvolyayushee medicinskim uchrezhdeniyam spravlyatsya s voznikayushej nagruzkoj 31 dekabrya 2019 goda Vsemirnaya organizaciya zdravoohraneniya byla proinformirovana ob obnaruzhenii sluchaev pnevmonii vyzvannoj neizvestnym vozbuditelem 3 yanvarya kitajskie sluzhby soobshili VOZ o 44 sluchayah pnevmonii v gorode Uhan provincii Hubej Patogen okazalsya novym koronavirusom nyne izvestnym kak SARS CoV 2 ranee pod vremennym nazvaniem 2019 nCoV kotoryj ranee ne obnaruzhivalsya sredi chelovecheskoj populyacii 30 yanvarya 2020 goda v svyazi so vspyshkoj epidemii VOZ obyavila chrezvychajnuyu situaciyu mezhdunarodnogo znacheniya v oblasti zdravoohraneniya a 28 fevralya 2020 goda VOZ povysila ocenku riskov na globalnom urovne s vysokih na ochen vysokie 11 marta 2020 goda epidemiya byla priznana pandemiej Pandemiya opasna tem chto odnovremennoe zabolevanie infekciej mnozhestva lyudej mozhet privesti k peregruzhennosti sistemy zdravoohraneniya s povyshennym kolichestvom gospitalizacij i letalnyh ishodov Sistemy zdravoohraneniya mogut okazatsya ne gotovy k neobychajno bolshomu kolichestvu tyazhelobolnyh pacientov Naibolee vazhnoj otvetnoj meroj po otnosheniyu k infekcii yavlyayutsya ne lechebnye meropriyatiya a snizhenie skorosti eyo rasprostraneniya chtoby rastyanut eyo vo vremeni i snizit takim obrazom nagruzku na sistemy zdravoohraneniya Epidemiya zakonchitsya kak tolko sredi naseleniya vyrabotaetsya dostatochnyj kollektivnyj immunitet Tem ne menee veroyaten scenarij po kotoromu virus zajmyot svoyo mesto sredi drugih ORVI i budet sosushestvovat s lyudmi eshyo dolgoe vremya Zabolevaniyu podverzheny lyudi vseh vozrastov mediannyj zhe vozrast lyudej s infekciej SARS CoV 2 sostavlyaet 50 let Tyazhyolye formy zabolevaniya chashe byvayut u pozhilyh lyudej vozrastom za 60 let s soputstvuyushimi zabolevaniyami Bolshinstvo molodyh lyudej i detej perenosyat zabolevanie v lyogkoj forme v tom chisle v vide lyogkoj pnevmonii ili asimptomaticheski V kitajskom otchyote s informaciej po 72 314 sluchayam zabolevaniya v 81 sluchaev zabolevanie prohodilo v lyogkoj forme v 14 v tyazhyoloj i v 5 sostoyanie pacientov bylo kriticheskim Prichiny zabolevaniya i ego razvitieVirusologiya Izobrazhenie virusa poluchennoe s pomoshyu elektronnogo mikroskopa Virus SARS CoV 2 okrashen zhyoltym cvetomOsnovnye stati SARS CoV 2 i Shtammy SARS CoV 2 Koronavirusnoe zabolevanie COVID 19 vyzyvaetsya ranee neizvestnym betakoronavirusom SARS CoV 2 kotoryj byl obnaruzhen v obrazcah zhidkosti vzyatoj iz lyogkih v gruppe pacientov s pnevmoniej v kitajskom gorode Uhan v dekabre 2019 goda SARS CoV 2 otnositsya k podrodu Sarbecovirus i yavlyaetsya sedmym po schyotu izvestnym koronavirusom sposobnym zarazhat cheloveka SARS CoV 2 yavlyaetsya RNK soderzhashim virusom s obolochkoj Na osnovanii issledovanij vydvinuta gipoteza chto virus yavlyaetsya rezultatom rekombinacii koronavirusa letuchih myshej s drugim poka eshyo ne izvestnym koronavirusom Predpolagaetsya chto cheloveku virus peredalsya ot pangolina Funkcionalnye sajty belka peplomera virusa SARS CoV 2 prakticheski identichny takovomu u virusa obnaruzhennogo u pangolinov Polnyj genom virusa rasshifrovan nahoditsya v otkrytom dostupe i dostupen v tom chisle cherez bazu GenBank Po mere svoej evolyucii u virusa proishodyat geneticheskie mutacii i formiruyutsya linii geneticheskih pokolenij vmeste sostavlyayushie derevo geneticheskih pokolenij Nekotorye mutacii mogut skazyvatsya na skorosti rasprostraneniya virusa na tyazhesti vyzyvaemogo im zabolevaniya ili na effektivnosti teh ili inyh metodov lecheniya Virusy s takimi mutaciyami nazyvayut variantami virusa ili shtammami Pri etom ne vse varianty yavlyayutsya shtammami novye shtammy poyavlyayutsya esli u varianta virusa izmenyayutsya fizicheskie svojstva V sootvetstvii s klassifikaciej predlozhennoj VOZ vyzyvayushie opaseniya varianty koronavirusa SARS CoV 2 imenuyut bukvami grecheskogo alfavita Po sostoyaniyu na noyabr 2021 goda vydelyayut shtammy Alfa Beta Delta Gamma i Omikron Peredacha infekcii Sm takzhe Mehanizm peredachi infekcii Virus peredayotsya vozdushno kapelnym putyom cherez vdyhanie melkih kapel raspylyonnyh v vozduhe pri kashle chihanii ili razgovore Kapli s virusom mogut popadat na poverhnosti i predmety a zatem inficirovat prikosnuvshegosya k nim cheloveka cherez posleduyushie prikosnoveniya k glazam nosu ili rtu Virus mozhet ostavatsya zhiznesposobnym v techenie neskolkih chasov popadaya na poverhnosti predmetov Na stalnyh poverhnostyah i na plastike on mozhet sohranyatsya do 2 3 dnej Issledovanie s silnym raspyleniem pokazalo chto virus mog by nahoditsya v vozduhe do neskolkih chasov odnako VOZ utochnyaet chto v estestvennyh i medicinskih usloviyah raspylenie proishodit inym sposobom a o peredache virusa po vozduhu poka ne soobshalos Hotya zhiznesposobnyj virus mozhet soderzhatsya v vydelyaemyh fekaliyah net kakih libo dokazatelstv vozmozhnosti zarazheniya fekalno oralnym putyom Est takzhe soobsheniya o tom chto virus obnaruzhivalsya v krovi i slyune Zaraznymi yavlyayutsya asimptomaticheskie presimptomaticheskie i simptomaticheskie inficirovannye Naibolee zaraznym schitaetsya period nezadolgo do razvitiya simptomov i na rannej stadii zabolevaniya Na dolyu presimptomaticheskih inficirovannyh mozhet prihoditsya bolee poloviny vseh sluchaev peredachi infekcii Chto kasaetsya asimptomaticheskih inficirovannyh poka neponyatno naskolko znachimaya rol prinadlezhit peredache infekcii v dannom sluchae Odnako massovaya vakcinaciya sposobstvuet umensheniyu doli simptomaticheskih sluchaev v rezultate chego rol asimptomaticheskih infekcij v peredache mozhet vozrasti Est soobsheniya o peredache infekcii ot cheloveka domashnim koshkam tigram i lvam Eksperimentalno vyyasneno chto virus mozhet legko peredavatsya mezhdu domashnimi koshkami Vozmozhnost peredachi ot koshek k cheloveku trebuet dalnejshih issledovanij Predpolozhitelno virus effektivnee peredayotsya v suhih i holodnyh usloviyah a takzhe v tropicheskih s vysokoj absolyutnoj vlazhnostyu Poka est lish kosvennye svidetelstva v polzu zimnej sezonnosti v severnom polusharii Odnako analiz korrelyacionnyh svyazej mezhdu meteorologicheskimi parametrami i skorostyu rasprostraneniya infekcii v kitajskih gorodah ne vyyavil vzaimosvyazi skorosti rasprostraneniya s temperaturoj okruzhayushej sredy Patogenez Posle popadaniya v dyhatelnye puti osnovnymi mishenyami virusa stanovyatsya epitelialnye kletki dyhatelnyh putej alveolyarnye epitelialnye kletki i endotelialnye kletki sosudov Virus popadaet v kletku prisoedineniem belka peplomera k receptoru angiotenzinprevrashayushemu fermentu 2 APF2 kletki Etim zhe putyom proishodilo proniknovenie v sluchae virusa SARS CoV odnako strukturnyj 3D analiz peplomera na poverhnosti virusa v sluchae SARS CoV 2 predpolagaet vozmozhno bolee silnoe vzaimodejstvie s receptorom Vhodu v kletku takzhe sposobstvuet predvaritelnaya preaktivaciya peplomera furinom kotoraya otsutstvovala u virusa SARS CoV Posle prisoedineniya k receptoru virus SARS CoV 2 ispolzuet receptory kletki i endosomy dlya proniknoveniya Pomogaet proniknoveniyu transmembrannaya serinovaya proteaza 2 TMPRSS2 Posle popadaniya virusa v nos v techenie neskolkih dnej proishodit lokalnaya replikaciya virusa i ego rasprostranenie po soobshayushimsya dyhatelnym putyam na etom etape infekciya protekaet bessimptomno s ogranichennym immunnym otvetom no chelovek yavlyaetsya zaraznym a virus obnaruzhivaetsya analizom mazka iz nosa Dalee proishodit rasprostranenie infekcii na ostalnye chasti verhnih dyhatelnyh putej v rezultate chego mogut vozniknut simptomy lihoradki nedomoganiya i suhogo kashlya Na etom etape inficirovannye kletki vysvobozhdayut angl interferony beta i gamma a immunnogo otveta mozhet hvatit dlya predotvrasheniya dalnejshego rasprostraneniya infekcii chto proishodit u bolshinstva zabolevshih Adekvatnyj kletochnyj immunnyj otvet cherez CD4 i CD8 T kletki associiruetsya s bolee lyogkim techeniem zabolevaniya U primerno pyatoj chasti zabolevshih infekciya rasprostranyaetsya na nizhnie dyhatelnye puti s razvitiem bolee tyazhyolyh simptomov Pri etom po sravneniyu s drugimi virusami alveolyarnye makrofagi igrayushie znachimuyu rol na rannih stadiyah infekcij ne vyrabatyvayut interferony v otvet na vozdejstvie virusa mehanizm chego poka neizvesten Vospalenie i povyshenie svyortyvaemosti krovi yavlyayutsya estestvennymi zashitnymi mehanizmami organizma odnako v tyazhyolyh sluchayah oni mogut usugublyat zabolevanie Naibolshuyu znachimost dlya ishoda zabolevaniya igraet techenie infekcii v lyogkih Iz za porazheniya alveol virusom voznikaet mestnaya vospalitelnaya reakciya s vybrosom bolshogo kolichestva citokinov sredi kotoryh IL 6 IL 1 faktor nekroza opuholi a i interferon gamma Aktivnaya replikaciya virusa v lyogkih pomimo respiratornyh simptomov privodit k lihoradke bolyam v myshcah i golovnoj boli Povyshennye urovni provospalitelnyh citokinov korreliruyut s tyazhyolym techeniem pnevmonii i usileniem effekta matovogo stekla v lyogkih Sam zhe effekt matovogo stekla voznikaet iz za chastichnogo zapolneniya alveol zhidkostyu kletochnym detritom gialinovymi membranami i vospalitelnymi kletkami v rezultate chego iz za smesheniya vozduha v alveolah nablyudaetsya pomutnenie v lyogkih no bronhi i sosudy pri etom ostayutsya razlichimymi Pomimo narushenij raboty dyhatelnoj sistemy u bolnyh mogut nablyudatsya nevrologicheskie serdechno sosudistye kishechnye narusheniya a takzhe narusheniya raboty pochek Odnako v dannyh napravleniyah o patogeneze poka malo chto izvestno Tyazhyolye sluchai COVID 19 takzhe svyazyvayut s koagulopatiej Virus inficiruet i porazhaet endotelialnye kletki vystilayushie sosudy lyogkih v rezultate chego narushaetsya normalnoe funkcionirovanie sosudov i podderzhanie ih tonusa a v dalnejshem izmeneniya privodyat k povysheniyu svyortyvaemosti krovi i obrazovaniyu trombov V odnom issledovanii obnaruzhena vzaimosvyaz mezhdu tromboobrazovaniem i nalichiem protromboticheskih autoantitel u pacientov chto shozhe s antifosfolipidnym sindromom pri etom dannye autoantitela privodyat k povyshennoj aktivnosti nejtrofilov Trombocitopeniya yavlyaetsya sledstviem zahvata trombocitov v mikrotrombah pri etom na obrazovanie trombov rashoduyutsya faktory svyortyvaniya krovi na deficit kotoryh ukazyvaet udlinyonnoe protrombinovoe vremya D dimer obrazuetsya v rezultate rasshepleniya fibrina plazminom a povyshennoe kolichestvo D dimera mozhet ukazyvat na izbytok polimerizovannogo fibrina vnutri sosudov i vo vnesosudistom prostranstve Povyshennye urovni D dimera fibrinogena i angl so znachitelno ponizhennym urovnem antitrombina sluzhat indikatorami plohogo prognoza u pacientov s COVID 19 Vysokij uroven virusovydeleniya v glotke nablyudaetsya v pervuyu nedelyu s poyavleniya simptomov dostigaya naibolshego urovnya na 4 j den chto predpolagaet aktivnuyu replikaciyu virusa v verhnih dyhatelnyh putyah Prodolzhitelnost virusovydeleniya posle ischeznoveniya simptomov zabolevaniya ocenivaetsya v 8 20 dnej Odnako obnaruzhenie RNK virusa posle vyzdorovleniya ne oznachaet nalichiya zhiznesposobnogo virusa Immunitet Sm takzhe Serologicheskie testy Naibolshee kolichestvo antitel protiv SARS CoV 2 vyrabatyvaetsya cherez dve tri nedeli posle zarazheniya posle chego ih kolichestvo nachinaet snizhatsya Gumoralnyj immunnyj otvet proyavlyaetsya vyrabotkoj antitel IgA IgM i IgG obnaruzhivaemyh v plazme krovi i slyune Pri etom v tyazhyolyh sluchayah infekcii po sravneniyu s lyogkimi nablyudayutsya bolee vysokie titry antitel IgA i IgG V techenie 3 5 mesyacev posle infekcii urovni IgM i IgA snizhayutsya V odnom issledovanii titry nejtralizuyushih antitel IgG sohranyalis dlitelnoe vremya s nebolshim snizheniem spustya 6 mesyacev posle zabolevaniya Rol kletochnogo immuniteta poka vyyasnyaetsya Sredi lyudej passivnaya immunizaciya antitelami pokazyvala ogranichennyj effekt chto predpolagaet vozmozhnuyu znachimuyu rol T kletok v kontrole infekcionnogo processa Vydelenie RNK virusa snizhaetsya s nastupleniem vyzdorovleniya i mozhet prodolzhatsya nekotoroe vremya ot dnej do nedel odnako eto ne oznachaet nalichie zhiznesposobnogo virusa V issledovanii s uchastiem 12 541 medicinskih rabotnikov postinfekcionnyj immunitet znachitelno snizhal risk reinfekcii v techenie 6 mesyacev posle perenesyonnoj infekcii pri etom sredi perebolevshih u kotoryh nablyudalis antitela IgG k spajkovomu belku ne bylo simptomaticheskih infekcij a podtverzhdyonnyh asimptomaticheskih infekcij bylo vsego dve Odnako po issledovaniyu nevozmozhno sudit o tom obespechivalas li zashita gumoralnym immunitetom ili zhe immunitetom kletochnym O sluchayah reinfekcii poyavlyayutsya soobsheniya povsemestno Soglasno sistematicheskomu obzoru ot avgusta 2021 goda po itogam primerno goda s nachala pandemii reinfekcii voznikali primerno u 3 chelovek na 1000 ranee vyzdorovevshih pacientov Hotya SARS CoV 2 obladaet sposobnostyu obhoda vrozhdyonnogo immuniteta predpolagaetsya chto bolshoe kolichestvo lyogkih i asimptomaticheskih sluchaev obyasnyaetsya rabotoj adaptivnogo immuniteta vsledstvie ranee perenesyonnyh infekcij vyzvannyh cirkuliruyushimi sredi naseleniya koronavirusami prostudy U 40 60 ne perebolevshih COVID 19 lic obnaruzhivayutsya kross reaktivnye CD4 T kletki kotorye mogut obespechivat chastichnyj immunitet ot COVID 19 Obnaruzhivayutsya i kross reaktivnye k SARS CoV 2 antitela kotorye sposobny raspoznavat virus SARS CoV 2 Vozmozhno chto nalichie kross reaktivnogo immuniteta vliyaet na tyazhest perenosimoj infekcii i na eyo raspredelenie po vozrastam Deti obychno chashe boleyut koronavirusnymi infekciyami chto gipoteticheski mozhet davat im nekotoruyu zashitu ot COVID 19 Alternativno bolshoe kolichestvo asimptomaticheskih sluchaev mozhet okazatsya sledstviem otlozhennogo immunnogo otveta interferonami tipa I poskolku nesmotrya na aktivnuyu replikaciyu virusa nablyudaetsya nizkaya vyrabotka interferonov I tipa i provospalitelnyh citokinov i hemokinov chto v sluchae zabolevaniya privodit k zaderzhke v poyavlenii simptomov Takzhe est svedeniya chto primerno cherez 6 mesyacev posle pervonachalnogo zarazheniya zashita ot povtornogo sostavlyala primerno 80 bez sushestvennoj raznicy v pokazatelyah povtornogo zarazheniya mezhdu muzhchinami i zhenshinami No dlya lic v vozraste 65 let i starshe eta zashita umenshaetsya do 47 V drugom issledovanii na protyazhenii 9 mesyacev brali analizy u bolee chem 9500 chelovek iz primerno 3500 sluchajno vybrannyh domohozyajstv v Uhane v rezultate okolo 40 inficirovannyh vyrabatyvali nejtralizuyushie antitela kotorye mozhno bylo obnaruzhit za ves period issledovaniya Klinicheskaya kartinaDlya infekcii vyzyvaemoj virusom SARS CoV 2 inkubacionnyj period sostavlyaet 1 14 dnej mozhet protekat bessimptomno v lyogkoj forme i v tyazhyoloj forme s riskom smerti no polnaya klinicheskaya kartina poka eshyo ne yasna Simptomy razvivayutsya v srednem na 5 6 den s momenta zarazheniya Est edinichnye soobsheniya o sluchayah dlitelnogo inkubacionnogo perioda odnako oni mogut okazatsya rezultatom vozmozhnogo povtornogo vozdejstviya virusa v ostalnyh zhe issledovaniyah inkubacionnyj period ne prevyshaet 10 6 dnej Pacienty s lyogkimi simptomami obychno vyzdoravlivayut v techenie nedeli V srednem dlitelnost simptomov ne prevyshaet 20 dnej V obshem sluchae po stepeni tyazhesti zabolevanie mozhet byt lyogkogo i srednego techeniya vklyuchaya lyogkuyu pnevmoniyu tyazhyolym s odyshkoj i gipoksiej kriticheskim s dyhatelnoj nedostatochnostyu shokom ili narusheniem raboty organov Progressirovanie bolezni po mediannomu kolichestvu dnej s momenta poyavleniya simptomov v skobkah razbros ot minimalnogo do maksimalnogo Sostoyanie DenGospitalizaciya 7 4 8 Odyshka 8 5 13 Ostryj respiratornyj distress sindrom 9 8 14 Mehanicheskaya ventilyaciya lyogkih 10 5 7 14 Perevod v otdelenie reanimacii 10 5 Po dannym odnogo issledovaniya u vseh pacientov postupivshih v bolnicu obnaruzhivaetsya pnevmoniya s infiltratami na rentgenovskom snimke Osobennostyu bolezni vyyavlyaemoj cherez kompyuternuyu tomografiyu yavlyayutsya dvustoronnie izmeneniya po tipu matovogo stekla zatragivayushie v osnovnom nizhnie otdely lyogkih i rezhe srednij otdel pravogo lyogkogo V drugom issledovanii otkloneniya ot normy na snimkah obnaruzhivayutsya u 75 bolnyh Pri etom pnevmoniya mozhet obnaruzhivatsya i v asimptomaticheskih sluchayah infekcii U treti pacientov razvivaetsya ostryj respiratornyj distress sindrom Pri ostrom respiratornom distress sindrome mogut obnaruzhivatsya takzhe tahikardiya tahipnoe ili cianoz soprovozhdayushij gipoksiyu Takzhe na fone infekcii vozmozhny dyhatelnaya nedostatochnost sepsis i septicheskij infekcionno toksicheskij shok U beremennyh nekotorye simptomy zabolevaniya mogut byt shozhi s simptomami adaptacii organizma k beremennosti ili s pobochnymi yavleniyami voznikayushimi iz za beremennosti Takie simptomy mogut vklyuchat lihoradku odyshku i ustalost Zabolevaniyu podverzheny deti vseh vozrastov po sravneniyu so vzroslymi u detej zabolevanie obychno protekaet v menee tyazhyoloj forme odnako so shozhimi proyavleniyami vklyuchaya pnevmoniyu Oslozhneniya sredi detej takzhe vstrechayutsya rezhe i v bolee lyogkoj forme Soglasno analizu 2143 sluchaev zabolevaniya sredi detej tyazhyolye i kriticheskie sluchai nablyudayutsya lish v 5 9 sluchaev a bolee uyazvimymi dlya infekcii yavlyayutsya malenkie deti Takzhe u detej chashe chem u vzroslyh mozhet vstrechatsya odnovremennoe zarazhenie drugimi virusami Est soobsheniya o klasterah detej s mnogosistemnym vospalitelnym sindromom predpolozhitelno svyazannym s COVID 19 Bolezn proyavlyaetsya shozhe s sindromom Kavasaki i s infekcionno toksicheskim shokom Oslozhneniya U bolshinstva COVID 19 protekaet v lyogkoj ili srednej forme no v nekotoryh sluchayah COVID 19 vyzyvaet silnye vospalitelnye processy nazyvaemye citokinovym shtormom kotoryj mozhet privesti k smertelnoj pnevmonii i ostromu respiratornomu distress sindromu Pri etom profili citokinovogo shtorma mogut razlichatsya u raznyh pacientov Obychno COVID 19 soprovozhdaetsya sindromom vysvobozhdeniya citokinov pri kotorom nablyudaetsya povyshennyj uroven interlejkina 6 IL 6 korreliruyushego s dyhatelnoj nedostatochnostyu ostrym respiratornym distress sindromom i oslozhneniyami Povyshennye urovni provospalitelnyh citokinov mogut takzhe svidetelstvovat o razvitii vtorichnogo angl Vospalitelnye processy mogut zatronut serdechno sosudistuyu sistemu privodya k aritmiyam i miokarditu Ostraya serdechnaya nedostatochnost vstrechaetsya v osnovnom sredi tyazhelo ili kriticheski bolnyh pacientov Infekciya mozhet okazyvat dolgosrochnoe vozdejstvie na sostoyanie zdorovya serdechno sosudistoj sistemy V sluchae pacientov s serdechno sosudistymi zabolevaniyami v istorii boleznej mozhet potrebovatsya strogij kontrol ih sostoyaniya Vozmozhnye oslozhneniya COVID 19 ostryj respiratornyj distress sindrom ot 15 do 33 ostraya dyhatelnaya nedostatochnost 8 ostraya serdechnaya nedostatochnost ot 7 do 20 vtorichnaya infekciya ot 6 do 10 ostraya pochechnaya nedostatochnost ot 14 do 53 septicheskij shok ot 4 do 8 kardiomiopatii u 33 kriticheskih disseminirovannoe vnutrisosudistoe svyortyvanie u 71 pogibshih oslozhneniya beremennosti ne isklyuchayutsya Redkie oslozhneniya vklyuchayut mukormikoz i encefalit Encefalit vstrechaetsya lish primerno u 0 215 gospitalizirovannyh pacientov odnako sredi pacientov s tyazhyolym techeniem bolezni ego chastota uvelichivaetsya do 6 7 Gipervospalitelnyj sindrom svyazannyj s COVID 19 Sm takzhe Citokinovyj shtorm Pri COVID 19 opredelyalis povyshennye urovni nekotoryh citokinov Odnako chasto eti urovni byli v desyatki raz nizhe chem pri ORDS vyzvannym drugimi prichinami Eto otnositsya takzhe i k urovnyu provospalitelnogo citokina IL 6 yavlyayushegosya odnim iz osnovnyh markerov nalichiya citokinovogo shtorma Shirokoe priznanie termina citokinovyj shtorm i ego vedushej roli v patogeneze COVID 19 motivirovalo ispolzovanie immunomoduliruyushih metodov lecheniya takih kak kortikosteroidy v vysokih dozirovkah i ingibitory IL 6 kak v usloviyah klinicheskih ispytanij tak i neposredstvenno dlya lecheniya tyazhyolyh form COVID 19 Primenenie etih sredstv vo mnogom bylo sledstviem sinonimichnogo upotrebleniya termina sindrom vysvobozhdeniya citokinov po otnosheniyu k terminu citokinovyj shtorm Po etoj prichine v tyazhyolyh sluchayah COVID 19 primenyalis sredstva protiv sindroma vysvobozhdeniya citokinov odnako v sluchae COVID 19 uroven IL 6 klyuchevogo mediatora dlya sindroma vysvobozhdeniya citokinov na poryadki nizhe chem v tyazhyolyh sluchayah COVID 19 Mezhdu tem primenenie blokatora IL 6 mozhet snizit na odnu nedelyu otvet organizma v vide povysheniya urovnya C reaktivnogo belka i povysheniya temperatury tela chto povyshaet risk infekcii i odnovremenno mozhet zamaskirovat tradicionnye klinicheskie priznaki V celom ispolzovanie citokinovyh blokatorov vne randomizirovannyh ispytanij poka yavlyaetsya neopravdannym V posleduyushem sindrom citokinovogo shtorma v tyazhyolyh sluchayah COVID 19 poluchil nazvanie gipervospalitelnogo sindroma svyazannogo s COVID 19 V odnom iz issledovanij dlya dannogo sindroma uzhe vydvinuty kriterii diagnostiki v tom chisle v sravnenii s drugimi sindromami citokinovogo shtorma Opredelenie kriteriev diagnostiki yavlyaetsya vazhnym poskolku pozvolyaet opredelit pacientov kotorym mogut pomoch terapii napravlennye na lechenie citokinovogo shtorma Pri etom sindrom citokinogo shtorma v sluchae COVID 19 yavlyaetsya dostatochno unikalnym poskolku urovni ferritinov i IL 6 hot i povysheny no menshe po sravneniyu s drugimi sindromami citokinovogo shtorma a lyogkie porazhayutsya v pervuyu ochered v ramkah ORDS s predraspolozhennostyu k svyortyvaniyu krovi Odnim iz vozmozhnyh podhodov dlya rannego diagnostirovaniya citokinovogo shtorma sredi pacientov s COVID 19 yavlyaetsya vyyavlenie febrilnyh pacientov s giperferritinemiej Odnako iz za nizkogo urovnya citokinov po sravneniyu s drugimi sindromami citokinovogo shtorma no shozhimi urovnyami nekotoryh necitokinovyh biomarkerov sistemnoe vospalenie yavno otlichaetsya ot drugih sindromov citokinovogo shtorma i rassmatrivanie vospalitelnogo processa kak rezultata citokinovogo shtorma mozhet okazatsya nevernym Vozmozhno sleduet rassmotret drugie veroyatnye modeli vozniknoveniya disfunkcii vnutrennih organov V kachestve obyasneniya citokinovogo shtorma predlozhena versiya otlozhennogo immunnogo otveta interferonami I tipa Koronavirusy obladayut mehanizmami podavleniya otveta interferonami I tipa chto associiruetsya s tyazhyoloj stepenyu zabolevaniya Dannaya sposobnost pozvolyaet im obhodit vrozhdyonnyj immunitet v techenie pervyh 10 dnej zabolevaniya V rezultate nakoplennaya virusnaya nagruzka privodit k gipervospaleniyu i citokinovomu shtormu Issledovaniya krovi pacientov s COVID 19 pokazali chto vysokaya viremiya associiruetsya s povyshennymi otvetom interferonami I tipa i vyrabotkoj citokinov sovmestno vliyayushih na tyazhest zabolevaniya Podavlenie raboty genov stimuliruemyh interferonom odnovremenno s povyshennym urovnem aktivacii NF kB privodit k citokinovomu shtormu i gipervospaleniyu obnaruzhivaemyh u kriticheski bolnyh pacientov ProfilaktikaSm takzhe Profilaktika COVID 19 Vedutsya razrabotki vakcin po sostoyaniyu na nachalo sentyabrya 2020 goda byli opublikovany dannye o chetyryoh vakcinah kandidatah odna iz kotoryh razrabotana v Rossii Tri vakciny yavlyayutsya adenovirus vektornymi odna mRNK vakcina Odnako pered nachalom massovoj vakcinacii vse vakciny dolzhny pokazat svoyu bezopasnost i effektivnost v shirokomasshtabnyh klinicheskih ispytaniyah Individualnaya profilaktika Vsemirnaya organizaciya zdravoohraneniya VOZ dala obshie rekomendacii po snizheniyu riska zarazheniya SARS CoV 2 Primenenie medicinskih masok sredi naseleniyaregulyarno myt ruki s mylom ili spirtosoderzhashim sredstvom pri kashle ili chihanii prikryvat nos i rot sognutym loktem ili odnorazovoj salfetkoj s posleduyushim obyazatelnym mytyom ruk soblyudat distanciyu v 1 metr po otnosheniyu k drugim lyudyam v obshestvennyh mestah osobenno esli u nih nablyudayutsya respiratornye simptomy ili povyshennaya temperatura po vozmozhnosti ne trogat rukami nos rot i glaza pri nalichii lihoradki kashlya i zatrudnyonnogo dyhaniya obratitsya v medicinskoe uchrezhdenie za pomoshyu Hotya pri blagopriyatnyh usloviyah virus mozhet dnyami ostavatsya zhiznesposobnym na razlichnyh poverhnostyah on unichtozhaetsya menee chem za minutu obychnymi dezinficiruyushimi sredstvami takimi kak gipohlorit natriya i perekis vodoroda Upotreblenie alkogolya ne sposobstvuet unichtozheniyu virusa ne obespechivaet dezinfekcii polosti rta i glotki odnako okazyvaet razrushitelnoe vozdejstvie na immunnuyu sistemu organizma Upotreblenie alkogolya oslablyaet eyo i snizhaet zashitnye sposobnosti organizma protiv infekcionnyh zabolevanij Takzhe upotreblenie alkogolya yavlyaetsya faktorom riska razvitiya ostrogo respiratornogo distress sindroma Kurenie mozhet povyshat shansy na inficirovanie poskolku podnoshenie sigarety ko rtu povyshaet shansy na zanesenie virusa v rot cheloveka cherez ruki Rekomendacii dlya zabolevshih Medicinskie maski obychnomu naseleniyu rekomenduyutsya v sluchae nalichiya respiratornyh simptomov ili v sluchae uhoda za bolnym u kotorogo mozhet byt COVID 19 Issledovaniya grippa i grippopodobnyh zabolevanij pokazyvayut chto noshenie masok bolnymi mozhet predotvratit zarazhenie drugih lyudej i kontaminaciyu okruzhayushih veshej i poverhnostej Pri nalichii simptomov shozhih s COVID 19 VOZ rekomenduet bolnym noshenie masok s soblyudeniem instrukcij po ih pravilnomu ispolzovaniyu i utilizacii samoizolyaciyu konsultirovanie u medicinskih rabotnikov pri plohom samochuvstvii mytyo ruk i soblyudenie distancii po otnosheniyu k drugim lyudyam Zabolevshim rekomenduetsya nosit medicinskuyu ili hirurgicheskie maski VOZ rekomenduet ispolzovat pulsoksimetry dlya kontrolya nasysheniya krovi kislorodom i opredeleniya neobhodimosti obrasheniya za medicinskoj pomoshyu soglasno vremennym rekomendaciyam Minzdrava RF ot 08 04 2020 kislorodoterapiya pokazana pri znachenii SpO2 menee 93 Rekomendacii dlya zdorovyh Metaanaliz i sistematicheskij obzor primeneniya masok vo vremya pandemii pokazal chto oni ochen effektivny v predotvrashenii rasprostraneniya infekcii SARS CoV 2 pri shirokom primenenii sredi naseleniya Maski mogut predotvratit vdyhanie krupnyh ili melkih kapel s virusom Issledovaniya takzhe pokazyvayut chto maski sposobny filtrovat submikronnye chasticy pyli Rekomendacii zhe po nosheniyu masok v raznyh stranah mogut otlichatsya drug ot druga mnogie strany rekomenduyut primenenie tkanevyh masok ili drugih sredstv dlya zashity lica Rekomendacii VOZ v obshem sluchae svodyatsya k nosheniyu masok zdorovymi lyudmi v regionah s massovym rasprostraneniem infekcii ili pri nevozmozhnosti obespecheniya socialnogo distancirovaniya V usloviyah massovogo rasprostraneniya infekcii s nekotorymi ogovorkami rekomenduetsya nadevat maski v obshestvennyh mestah naprimer v magazinah na rabochih mestah v mestah provedeniya massovyh meropriyatij i v uchrezhdeniyah zakrytogo tipa v tom chisle v shkolah Maski polagaetsya menyat cherez kazhdye 2 3 chasa nosheniya odnorazovye maski ne prednaznacheny dlya povtornogo ispolzovaniya ili obrabotki mnogorazovye zhe neobhodimo obrabatyvat pered povtornym ispolzovaniem VOZ ne rekomenduet polagatsya na strategiyu nosheniya rezinovyh perchatok v obshestvennyh mestah kak meru snizheniya rasprostraneniya infekcii SARS CoV 2 effektivnym yavlyaetsya mytyo ruk Chelovek mozhet kontaminirovat nos ili glaza prikosnoveniem ruk kak bez perchatok tak i v nih Perchatki rekomenduetsya ispolzovat pri uhode za bolnymi ili pri uborke Pri etom vyyasnilos chto dlitelnoe primenenie perchatok mozhet privodit k dermatitu Izbezhat zarazheniya mozhno soblyudaya distanciyu pri nahozhdenii ryadom s bolnymi lyudmi i izbegaya kontakta s nimi a takzhe vozderzhivayas ot rukopozhatij VOZ vsem rekomenduet soblyudenie distancii po krajnej mere v 1 metr s drugimi lyudmi osobenno esli u nih est simptomy respiratornogo zabolevaniya V Rossii po sostoyaniyu na 17 noyabrya 2020 goda kontaktirovavshim polozhen domashnij karantin na 14 dnej vyjti iz kotorogo mozhno po istechenii etogo sroka bez neobhodimosti provedeniya laboratornogo testirovaniya esli ne poyavilis simptomy shozhie s COVID 19 Rekomendacii dlya medicinskih rabotnikov Sm takzhe Kontrol riska na rabochem meste vo vremya pandemii COVID 19 Medicinskim rabotnikam VOZ rekomenduet ispolzovat maski pri uhode za bolnymi a respiratory pri vypolnenii procedur vo vremya kotoryh mozhet proizojti raspylenie v vozduhe zhidkostej VOZ otmechaet chto medicinskie maski dolzhny byt zarezervirovany dlya medicinskih rabotnikov u naseleniya oni mogut sozdat lozhnoe oshushenie bezopasnosti i privesti k prenebrezheniyu drugimi merami profilaktiki v to vremya kak medicinskim rabotnikam maski neobhodimy Dlya predotvrasheniya rasprostraneniya vnutribolnichnoj infekcii v tom chisle sredi medicinskogo personala vazhno chtoby medicinskie rabotniki soblyudali mery predostorozhnosti Bazovye principy v rekomendaciyah VOZ vklyuchayut v sebya soblyudenie gigieny ruk i respiratornoj gigieny standartnye mery predostorozhnosti vklyuchaya noshenie pacientami masok medicinskimi rabotnikami sredstv individualnoj zashity slezhenie za chistotoj i othodami dopolnitelnye mery predostorozhnosti vklyuchaya adekvatnuyu ventilyaciyu pomeshenij noshenie medicinskih masok perchatok i prisposoblenij dlya zashity glaz ogranichenie kontaktov pacientov po vozmozhnosti pomeshenie ih v palaty s otricatelnym davleniem soblyudenie mer predostorozhnosti pri vypolnenii procedur pri kotoryh mozhet proizojti raspylenie v vozduhe kontaminirovannyh zhidkostej otnoshenie ko vsem laboratornym obrazcam kak k potencialno zaraznym V medicinskih uchrezhdeniyah takzhe rekomenduetsya chistit i provodit dezinfekciyu stolov stulev sten kompyuternoj tehniki i drugih poverhnostej Effektivnymi protiv SARS CoV 2 yavlyayutsya etilovyj spirt 70 90 osnovannye na hlore produkty naprimer gipohlorit perekis vodoroda bolee 0 5 Effektivnost sredstv personalnoj zashity Po dannym na iyun 2020 goda analiz primeneniya masok licevyh shitkov i soblyudeniya distancii mezhdu lyudmi opublikovannyj v Lancet dostoverno srednee kachestvo dokazatelstv pokazal chto znachitelno snizhaet veroyatnost zarazheniya soblyudenie distancii mezhdu lyudmi v 1 metr i bolee takim obrazom distancirovanie umenshaet rasprostranenie infekcii S gorazdo menshim urovnem dostovernosti nizkoe kachestvo dokazatelstv snizhaet veroyatnost zarazitsya noshenie masok i zashity glaz Specialisty vypolnivshie metaanaliz rekomenduyut soblyudat distanciyu s drugimi lyudmi bolshe odnogo metra a v lyudnyh mestah gde distanciyu soblyusti nevozmozhno predlagayut ispolzovat maski dlya lica ili respiratory i zashitu glaz licevye shitki ili ochki Pri etom issledovanie v hode kotorogo vizualizirovalos rasprostranenie kapel ot bolnogo cheloveka pokazalo chto licevye shitki sami po sebe ne mogut zamenit maski tak kak kapli s virusnymi chasticami mogut svobodno rasprostranyatsya v raznyh napravleniyah vokrug shitka Mery obshestvennoj profilaktiki Na vremya pandemii naibolee effektivnoj meroj predotvrasheniya rasprostraneniya infekcii yavlyaetsya kontrolirovanie eyo istochnikov vklyuchaya rannyuyu diagnostiku svoevremennoe opoveshenie o sluchayah zarazheniya izolyaciyu bolnyh a takzhe periodicheskoe opoveshenie naseleniya ob obstanovke i podderzhanie poryadka Mnogie strany prinimayut mery socialnogo distancirovaniya vklyuchaya ogranichenie peremeshenij mezhdu gorodami zakrytie shkol i universitetov perehod na udalyonnuyu rabotu i pomeshenie zabolevshih v karantin Podobnye mery mogut pomoch zamedlit skorost rasprostraneniya infekcii mogut svoditsya k minimumu ili otkladyvatsya Soglasno modeliruyushim issledovaniyam vo vremya pandemii COVID 19 karantin igraet vazhnuyu rol v zamedlenii rasprostraneniya infekcii i snizhenii smertnosti no bolshij effekt dostigaetsya vvedeniem karantina vmeste s drugimi merami profilaktiki ili kontrolya V silu togo chto sezonnye koronavirusy luchshe rasprostranyayutsya v zimnie mesyacy v stranah s vyrazhennoj smenoj sezonov v takih stranah zimoj imeet smysl usilenie mer po snizheniyu rasprostraneniya infekcii Vakcinoprofilaktika COVID 19 Osnovnaya statya Vakcina protiv COVID 19 Sm takzhe Vakcinaciya protiv COVID 19 v Rossii Vakcinaciya protiv COVID 19 prednaznachena dlya formirovaniya priobretyonnogo immuniteta protiv virusa SARS CoV 2 putyom trenirovki sobstvennoj immunnoj sistemy Iz za vozmozhnogo tyazhyologo techeniya zabolevaniya neobhodima bezopasnaya i effektivnaya vakcina kotoraya pomozhet zashitit lyudej chto osobenno vazhno dlya medicinskih rabotnikov i lyudej vhodyashih v gruppy riska Vo vsyom mire reguliruyushie organy nahodyatsya pod silnym davleniem ne tolko sistem zdravoohraneniya no takzhe pod politicheskim i ekonomicheski davleniem napravlennom na shirokomasshtabnoe primenenie vakcin vne klinicheskih ispytanij Razreshenie primeneniya vakcin kandidatov v ramkah chrezvychajnoj situacii v dolgosrochnoj perspektive mozhet privesti k prezhdevremennomu zaversheniyu issledovanij v hode kotoryh mogut vyyavitsya sluchai svyazannogo s vakcinaciej usilennogo techeniya zabolevaniya ili drugie pobochnye effekty V celom soglasno dannym sistematicheskogo obzora bolshinstvo vakcin yavlyaetsya bezopasnymi i effektivnymi rekomenduetsya vakcinaciya v dva etapa dvumya dozami Odnako dopolnitelnye issledovaniya neobhodimy dlya ocenki vakcin v dolgosrochnoj perspektive i dlya vyyasneniya vliyaniya takih parametrov kak vozrast i dozirovka Po dannym Vsemirnoj organizacii zdravoohraneniya po sostoyaniyu na 17 dekabrya 2020 goda v doklinicheskoj razrabotke bylo 166 vakcin kandidatov 56 vakcin kandidatov prohodili klinicheskie ispytaniya Iz chisla otechestvennyh vakcin v Rossii zaregistrirovany Gam Kovid Vak Sputnik V Epivakkorona i KoviVak Ne soderzhashie zhivogo virusa vakciny ne mogut vyzvat zabolevanie no poskolku vakciny treniruyut immunnuyu sistemu mogut voznikat takie simptomy kak lihoradka chto yavlyaetsya normalnoj reakciej organizma i svidetelstvuet o vozniknovenii immunnoj reakcii Zashita ot infekcii v sluchae dvuhkomponentnyh vakcin obychno formiruetsya v techenie dvuh nedel posle polnoj vakcinacii v sluchae odnokomponentnyh v techenie neskolkih nedel chto oznachaet chto v etot period organizm vsyo eshyo uyazvim dlya infekcii SARS CoV 2 Vakcina takzhe mozhet okazatsya poleznoj posle uzhe perenesyonnogo COVID 19 poskolku reinfekcii vozmozhny a zabolevanie associiruetsya s riskom tyazhyologo techeniya Vakcinaciya hotya i ne ustranyaet polnostyu risk zabolet snizhaet etot risk po sravneniyu s neprivitymi gruppami naseleniya Odnako v bolshej stepeni ona zashishaet ot riska razvitiya tyazhyologo zabolevaniya gospitalizacii i smerti yavlyayas vazhnym sredstvom sredi otvetnyh mer pandemii Vakcinaciya takzhe umenshaet veroyatnost zarazheniya drugih lyudej ot vakcinirovannogo cheloveka Alternativnye vakciny v profilaktike Issleduetsya takzhe vozmozhnost primeneniya protivopnevmokokkovyh vakcin dlya predotvrasheniya soputstvuyushih COVID 19 bakterialnyh infekcij Soglasno issledovaniyam na zhivotnyh i lyudyah vakcina BCZh obladaet immunomoduliruyushimi svojstvami odnako poka oni ne izucheny a ih harakteristiki neizvestny V otsutstvie dokazatelstv vozmozhnoj zashity ot COVID 19 VOZ ne rekomenduet primenenie vakciny BCZh dlya predotvrasheniya COVID 19 rekomendacii k primeneniyu svodyatsya lish dlya profilaktiki tuberkulyoza sredi novorozhdyonnyh v stranah s povyshennym riskom zabolevaemosti Sushestvuet issledovanie svyazyvayushee snizhenie tyazhesti techeniya COVID 19 s vakcinaciej privivkoj MMR pri etom issledovanie provedeno na nebolshoj vyborke vsego v 80 chelovek i ego vyvody trebuyut dalnejshego izucheniya V celom poka net dokazatelstv chto vakcina protiv kakoj libo drugoj infekcii mozhet zashitit ot COVID 19 DiagnostikaOsnovnaya statya Testirovanie na koronavirusnuyu infekciyu COVID 19 Vsemirnaya organizaciya zdravoohraneniya predostavila rekomendacii po diagnostirovaniyu zabolevaniya u lyudej s podozreniem na infekciyu SARS CoV 2 V Rossii virus SARS CoV 2 predlagaetsya diagnostirovat soglasno vremennomu algoritmu opublikovannomu Ministerstvom zdravoohraneniya RF takzhe v Rossii uzhe razrabotany sredstva dlya laboratornoj diagnostiki koronavirusa Laboratornaya diagnostika Polimeraznaya cepnaya reakciya Testovyj komplekt Centrov po kontrolyu i profilaktike zabolevanij SShA dlya laboratornogo opredeleniya koronavirusa SARS CoV 2 Diagnostirovat virus vozmozhno pri pomoshi polimeraznoj cepnoj reakcii s obratnoj transkripciej v realnom vremeni V sluchae podozreniya na infekciyu no otricatelnogo rezultata testa mozhet byt proizvedeno povtornoe vzyatie obrazcov dlya analiza iz raznyh uchastkov dyhatelnyh putej V odnom issledovanii s vyborkoj v 5700 pacientov v 3 2 sluchaev polozhitelnym byl rezultat vtorogo testirovaniya rezultat pervogo otricatelnym Serologicheskie testy V otlichie ot PCR testy na antitela ne opredelyayut nalichie aktivnogo virusa v organizme no opredelyayut nalichie immuniteta k nemu to est nalichie IgM i IgG antitel v krovi Esli obnaruzhivayutsya odnovremenno antitela IgG i IgM to eto oznachaet chto infekciya byla v techenie neskolkih predshestvuyushih nedel esli zhe obnaruzhivayutsya lish IgG to infekciya byla ranee Pri etom testy ne pokazyvayut vyzdorovel li chelovek Takim obrazom testy mogut ispolzovatsya dlya opredeleniya teh kto byl inficirovan Rentgenologicheskoe obsledovanie Pri podozrenii na pnevmoniyu rentgenovskij snimok mozhet pokazat infiltraty v oboih lyogkih rezhe lish v odnom Esli est priznaki pnevmonii no rentgenovskij snimok nichego ne pokazal bolee tochnaya kartina mozhet byt poluchena s pomoshyu kompyuternoj tomografii Soglasno vremennym rekomendaciyam Minzdrava RF ot 26 10 2020 luchevoe obsledovanie pokazano pri umerennom tyazhyolom i krajne tyazhyolom techenii ostroj respiratornoj infekcii a v sluchae lyogkogo zabolevaniya po konkretnym pokazaniya naprimer pri nalichii faktorov riska Uvelichenie kolichestva zatemnenij na snimkah belogo cveta i priblizhenie k kartine belogo lyogkogo oznachaet priblizhenie veroyatnogo letalnogo ishoda U detej kartina shozha so sluchayami u vzroslyh odnako virusnaya pnevmoniya obychno protekaet v lyogkoj forme poetomu otkloneniya ot normy mogut byt ne zamecheny na rentgenovskih snimkah a diagnoz mozhet okazatsya nevernyj Diagnosticheskie pokazateli i biomarkery Poskolku COVID 19 proyavlyaetsya v shirokom spektre klinicheskih form s raznymi stepenyami tyazhesti odnoj iz zadach diagnostiki yavlyaetsya takzhe svoevremennoe opredelenie pacientov u kotoryh zabolevanie s bolshej veroyatnostyu mozhet progressirovat v tyazhyoluyu formu Dlya etih celej trebuetsya opredelenie sootvetstvuyushih biomarkerov Silnym prediktorom smertnosti pri gospitalizacii yavlyaetsya uroven saturacii SaO2 nizhe 90 svoevremennoe vyyavlenie gipoksii i gospitalizaciya mogut pomoch v snizhenii smertnosti V zavisimosti ot tyazhesti techeniya zabolevaniya provoditsya sootvetstvuyushij rutinnyj analiz krovi dlya vedeniya pacienta i svoevremennogo reagirovaniya na izmeneniya ego sostoyaniya Uvelichennoe protrombinovoe vremya i povyshennyj uroven S reaktivnogo belka pri gospitalizacii byli associirovany s tyazhyolym techeniem COVID 19 i perevodom v otdelenie intensivnoj terapii V odnom iz nebolshih issledovanij pokazano chto u bolshinstva bolnyh uroven angl v krovi byl v norme odnako on byl povyshennym u 3 h iz 4 bolnyh u kotoryh byla obnaruzhena vtorichnaya bakterialnaya infekciya Soglasno metaanalizu ot 23 sentyabrya 2020 goda primerno u 3 iz 4 tyazhelo ili kriticheski bolnyh pacientov prokalcitonin ne povyshen odnako povyshennye urovni prokalcitonina svyazany s povyshennym riskom oslozhnenij prokalcitonin mozhet ukazyvat na risk povrezhdenij vnutrennih organov Pri etom uroven prokalcitonina obychno v norme pri pervichnom obsledovanii V tekushih rukovodstvah po lecheniyu COVID 19 poka ne utverzhdena strategiya po naznacheniyu antibiotikov soglasno urovnyu prokalcitonina dlya opredeleniya vozmozhnosti vyyavleniya vtorichnyh bakterialnyh infekcij na osnove prokalcitonina trebuyutsya dopolnitelnye issledovaniya Otricatelnyj zhe test na prokalcitonin mozhet ukazyvat na veroyatnoe otsutstvie bakterialnoj vtorichnoj infekcii Eozinopeniya takzhe chasto vstrechaetsya sredi pacientov no ne zavisit ot stepeni tyazhesti bolezni Eozinopeniya mozhet sluzhit markerom COVID 19 u bolnyh s podozreniem na infekciyu SARS CoV 2 esli prisutstvuyut sootvetstvuyushie simptomy i anomalii v rentgenovskih issledovaniyah U kriticheski bolnyh pacientov nablyudaetsya povyshennoe soderzhanie markerov vospalitelnyh processov v plazme krovi V nebolshom issledovanii otmecheno chto u pacientov popadayushih v otdelenie intensivnoj terapii v krovi vyshe urovni IL 2 IL 7 IL 10 angl angl MCP1 MIP1A i faktora nekroza opuholi FNO a angl sm Lejkocitarnaya formula sredi pacientov COVID 19 yavlyaetsya naibolee chastoj i vstrechaetsya primerno v 83 sluchaev V sluchayah s letalnym ishodom limfopeniya stanovilas bolee tyazhyoloj so vremenem vplot do smerti Pomimo limfopenii s tyazhyolym techeniem zabolevaniya takzhe mogut byt svyazany nejtrofiliya povyshennyj uroven alaninaminotransferazy i aspartataminotransferazy v syvorotke krovi povyshennyj uroven laktatdegidrogenazy vysokij uroven C reaktivnogo belka i vysokij uroven ferritinov Stepen tyazhesti zabolevaniya pri otsutstvii sepsisa opredelyaetsya ishodya iz stepeni nasysheniya arterialnoj krovi kislorodom i chastoty dyhaniya Na tyazhyoluyu stepen zabolevaniya takzhe mozhet ukazyvat obnaruzhenie RNK virusa v krovi pacienta Na sepsis mozhet ukazyvat uroven laktata v krovi ot 2 mmol l S letalnymi ishodami associiruyutsya povyshennyj uroven D dimera i limfopeniya Differencialnyj diagnoz Po simptomam COVID 19 nevozmozhno otlichit ot drugih ostryh respiratornyh infekcij v chastnosti ot prostudy i drugih ORVI Pnevmoniya pri COVID 19 takzhe ne mozhet byt klinicheski otlichimoj ot pnevmonij vyzvannyh drugimi patogenami Klyuchevym faktorom diagnostiki yavlyaetsya istoriya puteshestvij ili kontaktov bolnogo V sluchayah gruppovogo zabolevaniya pnevmoniej osobenno u voennosluzhashih mogut byt zapodozreny adenovirusnaya ili mikoplazmennaya infekcii Drugie infekcii mogut byt isklyucheny testami na konkretnyh vozbuditelej bakterialnaya pnevmoniya mozhet byt isklyuchena polozhitelnym posevom krovi ili mokroty libo molekulyarnym testirovaniem drugie virusnye infekcii cherez polimeraznuyu cepnuyu reakciyu s obratnoj traskripciej Diagnostirovat gripp mogut pomoch takzhe ekspress testy odnako ih otricatelnyj rezultat ne isklyuchaet gripp Polozhitelnyj zhe diagnoz na drugoj patogen ne isklyuchaet odnovremennogo zarazheniya virusom SARS CoV 2 koinfekcii V issledovanii s vyborkoj 5700 chelovek koinfekciya SARS CoV 2 i drugim respiratornym virusom obnaruzhivalas u 2 1 chelovek LecheniePoryadok nadevaniya sredstv individualnoj zashityKoronavirusnyj stacionar pri Sechenovskom universitete Antibiotiki protiv virusov bespolezny i ne primenyayutsya v lechenii Odnako oni mogut byt naznacheny v sluchae obnaruzheniya bakterialnoj vtorichnoj infekcii V osnovnom pacienty poluchayut simptomaticheskuyu i podderzhivayushuyu terapiyu Osnovnoj zadachej lecheniya bolnyh s ostroj dyhatelnoj nedostatochnostyu yavlyaetsya podderzhanie dostatochnogo urovnya oksigenacii organizma poskolku nedostatok kisloroda mozhet privesti k neobratimym narusheniyam v rabote zhiznenno vazhnyh organov i letalnomu ishodu V tyazhyolyh sluchayah lechenie napravleno na podderzhanie zhiznenno vazhnyh funkcij organizma Esli lechenie v stacionare po kakim libo prichinam nevozmozhno v lyogkih sluchayah bez trevozhnyh priznakov i pri otsutstvii hronicheskih boleznej dopustim uhod za bolnym v domashnih usloviyah Odnako pri nalichii odyshki krovoharkanya povyshennogo vydeleniya mokroty priznakov gastroenterita ili izmeneniyah psihicheskogo sostoyaniya pokazana gospitalizaciya VOZ takzhe preduprezhdaet chto kurenie primenenie narodnyh sredstv v tom chisle na osnove trav i samolechenie vklyuchaya antibiotiki nikak ne pomogut borotsya s infekciej no mogut nanesti vred zdorovyu Po sostoyaniyu na iyul 2022 goda sushestvuyut dokazatelstva vysokoj otmecheny H ili srednej stepeni dostovernosti po polozhitelnomu vliyaniyu na sleduyushie sobytiya Umenshenie smertnosti sistemnye kortikosteroidy ingibitory IL 6 H Risk IVL sistemnye kortikosteroidy H Risk gospitalizacii molnupiravir nirmatrelvir ritonavir Prodolzhitelnost gospitalizacii i vitamin D imeyut pryamye dokazatelstva effektivnosti a takzhe sistemnye kortikosteroidy Srok klinicheskogo vyzdorovleniya molnupiravir Srok IVL igibitory yanus kinaz Takzhe imeyutsya dokazatelstva nizkogo kachestva o vozmozhnoj effektivnosti po tem ili inym sobytiyam sleduyushih preparatov grupp preparatov sredstva ot virusnyh gepatitov azitromicin cefepim doksiciklin solevye rastvory favipiravir antikoagulyanty v terapevticheskih dozah vozmozhno umenshayut risk tromboza no pri etom mogut povyshat risk krovotechenij remdesivir i pri etom eta gruppa sredstv imeet dokazannyj vred v vide negativnogo profilya bezopasnosti Podderzhivayushee lechenie Pacientam so sluchayami srednej tyazhesti zabolevaniya i s tyazhyolymi sluchayami trebuetsya podderzhivayushee lechenie i kislorodnaya terapiya Vsemirnaya organizaciya zdravoohraneniya rekomenduet vsem stranam obespechit dostupnost ustrojstv dlya izmereniya urovnya kisloroda v krovi i medicinskih ustrojstv kislorodnoj terapii Ostryj respiratornyj distress sindrom predpolagaet mehanicheskuyu ventilyaciyu lyogkih V bolee tyazhyolyh sluchayah primenyaetsya ekstrakorporalnaya membrannaya oksigenaciya kotoraya yavlyaetsya slozhnym i kompleksnym metodom podderzhki pacientov pri ostroj gipoksicheskoj dyhatelnoj nedostatochnosti Etot metod primenyaetsya i pri tyazhyolyh formah serdechnoj nedostatochnosti kotoraya takzhe mozhet vozniknut na fone infekcii SARS CoV 2 Pacienty vyzhivshie posle kriticheskogo sostoyaniya ostrogo respiratornogo distress sindroma ili ekstrakorporalnoj membrannoj oksigenacii obychno prohodyat dlitelnyj etap reabilitacii i mogut provesti bolshe vremeni v stacionare Vsemirnaya organizaciya zdravoohraneniya opublikovala rukovodstvo po vedeniyu tyazhelobolnyh v sluchae podozreniya na novyj koronavirus V Kokranovskom sotrudnichestve takzhe byla podgotovlena specialnaya tematicheskaya podborka dokazatelnoj bazy v sootvetstvii s rekomendaciyami VOZ Podborka vklyuchaet v sebya informaciyu po zhidkostnoj reanimacii i primeneniyu vazopressorov po mehanicheskoj ventilyacii lyogkih i eyo otmene po lecheniyu gipoksii po farmakologicheskomu lecheniyu i po pitaniyu v otdeleniyah reanimacii Ekstrakorporalnaya membrannaya oksigenaciya Osnovnaya statya Ekstrakorporalnaya membrannaya oksigenaciya Pri ekstrakorporalnoj membrannoj oksigenacii EKMO venoznaya krov perenapravlyaetsya v specialnyj apparat s membranami po suti predstavlyayushimi soboj iskusstvennye lyogkie Krov nasyshaetsya kislorodom i iz neyo udalyaetsya uglekislyj gaz a zatem ona snova vozvrashaetsya v druguyu venu ili arteriyu Po tekushim dannym dannyj metod pomogaet snizit letalnost sredi pacientov s ostrym respiratornym distress sindromom Odnako sam po sebe metod yavlyaetsya resursoyomkim i dorogostoyashim sposobom podderzhaniya zhizni a v chisle oslozhnenij vozmozhny bolnichnye infekcii Hotya on mozhet pomoch pri dyhatelnoj ili serdechnoj nedostatochnosti on ne pomozhet v sluchae mnozhestvennogo otkaza organov ili septicheskogo shoka Poskolku na tekushij moment neizvestny sootnosheniya raznyh prichin smerti slozhno ocenit vozmozhnuyu polzu v celom ot primeneniya EKMO pri COVID 19 Soglasno kogortnomu issledovaniyu Organizacii ekstrakorporalnogo zhizneobespecheniya sredi pacientov s COVID 19 na 90 j den s nachala terapii vnutribolnichnaya smertnost sostavila 38 V naibolee bolshom randimizirovannom issledovanii primeneniya EKMO pri ostrom povrezhdenii lyogkih smertnost na 60 j den sostavlyala 35 protiv 46 v kontrolnoj gruppe Predvaritelnye dannye ukazyvayut na potencialnuyu polzu primeneniya EKMO v sluchayah COVID 19 V usloviyah epidemii primenenie EKMO ogranicheno kak i v sluchae pandemii V stranah s malymi resursami v takih sluchayah bolshe zhiznej mozhet byt spaseno primeneniem ustrojstv dlya izmereniya urovnya kisloroda v krovi i terapiej kislorodom Lechenie kortikosteroidami SARS CoV MERS CoV i SARS CoV 2 privodyat k bolshomu vybrosu citokinov vyzyvaya silnyj immunnyj otvet Immunnyj otvet yavlyaetsya odnoj iz prichin vozniknoveniya ostrogo povrezhdeniya lyogkih i ostrogo respiratornogo distress sindroma V nachale pandemii Kitaem primenyalis kortikosteroidy odnako VOZ ne rekomendovala ih ispolzovanie vne RKI iz za otsutstviya dokazatelstv vozmozhnoj effektivnosti kitajskaya zhe komanda medikov apellirovala utverzhdaya chto malye dozy pomogayut snizit smertnost Soglasno predvaritelnym rezultatam issledovaniya RECOVERY provedyonnogo v Velikobritanii deksametazon pomogaet na tret snizit smertnost pacientov nahodyashihsya na iskusstvennoj ventilyacii lyogkih i na pyatuyu chast sredi pacientov kotorym trebuetsya kislorodnaya terapiya Metaanaliz i sistematicheskij obzor lecheniya COVID 19 razlichnymi preparatami pokazyvaet chto glyukokortikosteroidy veroyatno vsyo zhe snizhayut smertnost i risk neobhodimosti mehanicheskoj ventilyacii lyogkih sredi pacientov v sravnenii s obychnym uhodom za bolnym Odnako 1707 pacientov v issledovanii ne podoshli dlya randomizacii a dannye o prichinah otkaza otsutstvuyut poetomu est nekotoraya neopredelyonnost po chasti pacientov s soputstvuyushimi zabolevaniyami Eksperimentalnoe lechenie Sm takzhe Eksperimentalnye terapii i napravleniya issledovanij Hotya na praktike primenyayutsya nelicenzirovannye preparaty i eksperimentalnye terapii naprimer s primeneniem protivovirusnyh sredstv podobnoe lechenie dolzhno prohodit v ramkah eticheski obosnovannyh klinicheskih issledovanij Issledovaniya serij sluchaev mogut byt predvzyatymi chto mozhet sozdat lozhnoe oshushenie bezopasnosti i effektivnosti eksperimentalnyh terapij Kriticheski vazhnym yavlyaetsya primenenie sredstv obosnovannyh kak nauchnymi issledovaniyami tak i eticheski VOZ podgotovila protokol dlya provedeniya randomizirovannyh kontroliruemyh issledovanij Provodimye issledovaniya dolzhny byt vysokokachestvennymi nizkoe kachestvo issledovanij privodit k pustoj trate resursov i po opredeleniyu ne yavlyaetsya etichnym Primenenie zhe sredstv s nedokazannoj effektivnostyu mozhet nanesti vred pacientam nahodyashimsya v kriticheskom sostoyanii Naprimer hlorohin gidroksihlorohin azitromicin a takzhe lopinavir i ritonavir associiruyutsya s potencialnym povysheniem riska smerti iz za problem s serdcem Naznacheniya terapij dolzhny osnovyvatsya ne na gipotezah a na klinicheskih issledovaniyah podtverzhdayushih effektivnost Gipotezy zhe mogut yavlyatsya osnovaniem dlya provedeniya splanirovannogo klinicheskogo ispytaniya VOZ schitaet eticheski dopustimym individualnoe primenenie eksperimentalnyh terapij vne klinicheskih issledovanij v svyazi s ekstrennoj situaciej esli pacient byl proinformirovan i dal svoyo soglasie Podobnye terapii dolzhny prohodit pod nablyudeniem a rezultaty dolzhny byt zadokumentirovany i predostavleny nauchnomu i medicinskomu soobshestvu Neeffektivnye lekarstva V metaanalize The LIVING Project provedyon obzor issledovanij terapij po razlichnym kriteriyam v chisle kotoryh snizhenie smertnosti ot vseh prichin na 20 snizhenie riska seryoznyh oslozhnenij na 20 i snizhenie riska mehanicheskoj ventilyacii lyogkih na 20 Soglasno metaanalizu est dokazatelstva neeffektivnosti gidroksihlorohina i kombinacii lopinavira i ritonavira v snizhenii smertnosti ot vseh prichin i snizheniya riska seryoznyh oslozhnenij Kombinaciya lopinavira i ritonavira takzhe neeffektivna po chasti snizheniya riska neobhodimosti mehanicheskoj ventilyacii lyogkih Net dokazatelstv effektivnosti ili neeffektivnosti po sravneniyu so standartnym uhodom dlya sleduyushih sredstv interferon b 1a i kolhicin Lopinavir Ritonavir Ne imeet preimushestv pered standartnym lecheniem podderzhivayushej terapiej ni v monoterapii ni v sochetanii s umifenovirom ili interferonami pri etom znachitelno povyshaet risk pobochnyh effektov Gidroksihlorohin Po opytu lecheniya malyarii i sistemnoj krasnoj volchanki hlorohina i gidroksihlorohina oba preparata otnositelno horosho perenosyatsya pacientami odnako obladayut seryoznymi pobochnymi effektami v menee 10 sluchaev sredi kotoryh angl gipoglikemiya psihonevrologicheskie pobochnye effekty i retinopatiya Rannie rezultaty lecheniya etimi preparatami pokazali obnadyozhivayushie rezultaty v svete chego ih ispolzovanie poluchilo odobrenie Donalda Trampa vposledstvii zhe metaanaliz i sistematicheskij obzor issledovanij primeneniya gidroksihlorohina pokazal chto on ne snizhaet smertnost sredi gospitalizirovannyh pacientov Odnako v kombinacii s azitromicinom on naoborot uvelichivaet smertnost Primenenie aminohinolinov v lechenii COVID 19 besperspektivno esli tolko ne poyavyatsya novye vysokokachestvennye issledovaniya s inymi rezultatami Kogortnoe issledovanie pacientov s revmaticheskimi narusheniyami prinimavshih gidroksihlorohin ne obnaruzhilo kakogo libo profilakticheskogo effekta Analogichnye rezultaty pokazalo randomizirovannoe issledovanie profilaktiki posle vozmozhnogo zarazheniya pri etom v gruppe gidroksihlorohina chashe nablyudalis pobochnye effekty Azitromicin Po rezultatam semi issledovanij s uchastiem 8822 pacientov bylo vyyavleno chto azitromicin ne vliyaet na smertnost risk i prodolzhitelnost IVL i prodolzhitelnost gospitalizacii Poetomu lechenie azitromicinom COVID 19 ne opravdano iz za nedostatochnoj effektivnosti i vysokogo riska formirovaniya antibiotikorezistentnosti Rekonvalescentnaya plazma Immunnaya sistema proizvodit antitela kotorye pomogayut v borbe s virusom Rekonvalescentnaya plazma soderzhit antitela i mozhet ispolzovatsya v celyah passivnoj immunizacii drugih lyudej putyom perelivaniya imeetsya uspeshnyj opyt ispolzovaniya podobnoj praktiki v lechenii nekotoryh virusnyh zabolevanij Kokrejnovskij meta analiz po rekonvalescentnoj plazme utverzhdaet na osnovanii vosmi RKI ocenivayushih effektivnost i bezopasnost plazmy vyzdoravlivayushih chto s vysokoj stepenyu dostovernosti rekonvalescentnaya plazma ne vliyaet ili prakticheski ne vliyaet ni na smertnost v techenie 28 dnej ni na klinicheskoe uluchshenie bolnyh COVID 19 srednej ili tyazhyoloj stepeni tyazhesti Centry po kontrolyu i profilaktike zabolevanij SShA rekomenduyut ne ispolzovat rekonvalescentnuyu plazmu s nizkimi titrami antitel plazmu s vysokimi titrami rekomenduetsya ne ispolzovat u gospitalizirovannyh bolnyh bez narushenij v rabote immunnoj sistemy za isklyucheniem primeneniya v ramkah klinicheskih ispytanij sredi pacientov kotorym ne trebuetsya mehanicheskaya ventilyaciya lyogkih Dlya kakih libo rekomendacij za ili protiv primeneniya sredi negospitalizirovannyh pacientov ili sredi bolnyh s narusheniyami raboty immunnoj sistemy poka nedostatochno dannyh Postkovidnyj sindromOsnovnaya statya Postkovidnyj sindrom Inogda v rezultate perenesyonnogo zabolevaniya voznikayut dolgovremennye oslozhneniya poluchivshie nazvanie postkovidnyj sindrom Tochnogo opredeleniya postkovidnogo sindroma net Soglasno statistike Velikobritanii primerno u kazhdogo pyatogo bolnogo s podtverzhdyonnym diagnozom simptomy dlilis 5 nedel ili dolshe a u kazhdogo 10 go 12 nedel i dolshe Obychno postkovidnyj sindrom opredelyaetsya kak simptomy dlitelnostyu bolee 2 mesyacev Simptomy mogut vklyuchat v sebya ustalost odyshku boli ili oshushenie sdavlivaniya v grudi problemy s pamyatyu i koncentraciej vnimaniya problemy so snom uchashyonnoe serdcebienie golovokruzhenie oshusheniya pokalyvaniya boli v sustavah depressiya i trevozhnost zvon ili bolevye oshusheniya v ushah boli v zhivote diareya poterya appetita vysokaya temperatura tela kashel golovnye boli bol v gorle izmeneniya obonyaniya ili vkusa syp poteryu volos Multisistemnyj vospalitelnyj sindrom svyazannyj s COVID 19Osnovnaya statya Sindrom multisistemnogo vospaleniya u detej i podrostkov Etot razdel stati eshyo ne napisan Zdes mozhet raspolagatsya otdelnyj razdel Pomogite Vikipedii napisav ego 24 iyunya 2021 Samostoyatelnaya reabilitaciyaPosle perenesyonnoj tyazhyoloj formy COVID 19 nekotorym mozhet potrebovatsya reabilitaciya na domu Reabilitacionnye meropriyatiya mogut vklyuchat v sebya metody kupirovaniya odyshki vypolnenie povsednevnyh dejstvij opredelyonnye fizicheskie uprazhneniya vosstanovlenie problem svyazannyh s golosom ili s priyomom pishi preodolenie trudnostej svyazannyh s pamyatyu ili myshleniem i reshenie problem svyazannyh so stressom Vrach pri vypiske mozhet naznachit individualnye rekomendacii po reabilitacii a pomosh mozhet okazyvatsya semyoj ili druzyami Pri nekotoryh sostoyaniyah vo vremya reabilitacii mozhet potrebovatsya obrashenie k vrachu Soglasno VOZ obrashenie k vrachu trebuetsya esli odyshka ne snizhaetsya nesmotrya na ispolzovanie metodov kontrolya dyhaniya v sostoyanii pokoya silnaya odyshka voznikaet pri vypolnenii minimalnoj fizicheskoj aktivnosti dazhe v polozheniyah predpolagayushih oblegchenie odyshki net vidimogo uluchsheniya umstvennyh processov i snizheniya ustalosti v rezultate chego zatrudnyaetsya povsednevnaya deyatelnost ili ne poluchaetsya vernutsya k sluzhebnyh obyazannostyam voznikayut simptomy toshnoty golovokruzheniya silnoj odyshki oshusheniya lipkoj kozhi povyshennogo potootdeleniya oshusheniya sdavlivaniya v grudi ili esli usilivayutsya boli PrognozLetalnost po stranam po sostoyaniyu na 1 aprelya 2020 g Strana LetalnostItaliya 11 7 Ispaniya 8 7 Velikobritaniya 7 1 Iran 6 5 Kitaj 2 3 SShA 1 7 Germaniya 1 Avstraliya 0 4 V sluchae Kitaya privedena itogovaya letalnost po 72 314 sluchayam s 31 dekabrya 2019 po 11 fevralya 2020 goda Letalnost i tyazhest zabolevaniya svyazany s vozrastom pacientov i nalichiem soputstvuyushih zabolevanij Osnovnoj prichinoj letalnyh ishodov yavlyaetsya dyhatelnaya nedostatochnost razvivayushayasya na fone ostrogo respiratornogo distress sindroma Takzhe vyzdorovleniyu mogut prepyatstvovat shok i ostraya pochechnaya nedostatochnost Soglasno analizu 44 672 podtverzhdyonnyh sluchaev v Kitae iz obshego chisla v 72 314 sluchaev po dannym s 31 dekabrya 2019 goda po 11 fevralya 2020 goda letalnost sostavlyala 2 3 Sredi pogibshih bylo bolshe pozhilyh lyudej vozrastom ot 60 let i lyudej s hronicheskimi boleznyami Sredi kriticheski bolnyh letalnost sostavlyala 49 Itogovaya letalnost sredi pacientov bez soputstvuyushih zabolevanij v Kitae byla namnogo nizhe i sostavlyala 0 9 Uroven letalnosti mozhet otlichatsya mezhdu stranami v nekotoryh stranah uroven letalnosti okazalsya vyshe chem v Kitae V celom po miru po sostoyaniyu na 8 aprelya on ocenivalsya primerno v 5 85 Letalnost sredi gospitalizirovannyh variruetsya ot 4 do 11 Na razlichiya mezhdu stranami mogut vliyat razlichnye faktory Naprimer vysokaya letalnost v Italii v nachale pandemii chastichno obyasnyaetsya bolshim kolichestvom pozhilogo naseleniya v strane V sravnenii s tyazhyolym ostrym respiratornym sindromom i blizhnevostochnym respiratornym sindromom letalnost u COVID 19 namnogo nizhe Odnako zabolevanie COVID 19 legche rasprostranyaetsya i uzhe otnyalo namnogo bolshe zhiznej Faktory riskaV chislo faktorov sposobstvuyushih bolshej veroyatnosti protekaniya bolezni v tyazhyoloj forme vhodyat pozhiloj vozrast muzhskoj pol diabet ozhirenie kurenie v anamneze hronicheskie zabolevaniya lyogkih HOBL serdechnye zabolevaniya ishemicheskaya bolezn gipertoniya hronicheskie zabolevaniya pochek hronicheskie zabolevaniya pecheni zlokachestvennye novoobrazovaniya VICh infekciya Astma sudya po vsemu ne yavlyaetsya faktorom riska dlya COVID 19 po dannym zhe Centrov po kontrolyu i profilaktike zabolevanij SShA faktorami riska mogut okazatsya astma srednej tyazhesti i tyazhyolaya forma Beremennost yavlyaetsya faktorom riska v sluchae tyazhyologo techeniya zabolevaniya chashe trebuetsya intensivnaya terapiya pri otsutstvii zhe tyazhyologo techeniya zabolevanie prohodit legche chem u neberemennyh Pri etom vazhno uchityvat chto beremennye zhenshiny i novorozhdyonnye mladency mogut s bolshej veroyatnostyu nuzhdatsya v specializirovannoj pomoshi vne zavisimosti ot COVID 19 Soglasno sistematicheskomu obzoru zheludochno kishechnyh proyavlenij nalichie simptomov gastroenterita povyshaet risk razvitiya tyazhyologo ili kriticheskogo sostoyaniya a takzhe ostrogo respiratornogo distress sindroma Iz serdechnyh zabolevanij risk smerti povyshayut koronarnaya nedostatochnost serdechnaya nedostatochnost i aritmii Kurenie yavlyaetsya faktorom riska dlya mnogih infekcionnyh i neinfekcionnyh zabolevanij v tom chisle dlya respiratornyh Issledovaniya pokazyvayut chto u kurilshikov bolee vysokij risk razvitiya tyazhyoloj formy COVID 19 i letalnogo ishoda Vozmozhno chto povyshennyj risk razvitiya tyazhyologo zabolevaniya u muzhchin takzhe svyazan s tem chto muzhchiny chashe kuryat nezheli zhenshiny Shansy na progressirovanie do tyazhyoloj formy zabolevaniya uvelichivayutsya u lyudej s bolee dlitelnoj istoriej kureniya Vozmozhno eto svyazano s tem chto dlitelnoe kurenie mozhet privesti k razvitiyu hronicheskoj obstruktivnoj bolezni lyogkih HOBL Sama po sebe HOBL znachitelno uvelichivaet risk razvitiya tyazhyoloj formy Uchyonye takzhe vyyavili chto primerno u 10 bolnyh s ugrozhayushej zhizni formoj zabolevaniya obnaruzhivayutsya antitela k interferonu v 95 sluchaev sredi muzhchin Eksperimenty podtverdili chto eti antitela blokiruyut rabotu interferona I tipa Eshyo u 3 5 chelovek obnaruzhivayutsya mutacii 13 razlichnyh genov kotorye igrayut kriticheskuyu rol v zashite ot virusov grippa V oboih sluchayah narusheniya svyazany s vyrabotkoj i rabotoj nabora iz 17 belkov iz gruppy interferonov I tipa zashishayushih kletki i organizm v celom ot virusov Eksperimentalnye terapii i napravleniya issledovanijV celyah opredeleniya effektivnyh terapij VOZ zapustila mezhdunarodnoe issledovanie Solidarity kotoroe budet izuchat effektivnost primeneniya razlichnyh terapij po sravneniyu s obychnym podderzhivayushim lecheniem Rezultaty issledovaniya s uchastiem bolee 30 stran byli opublikovany v vide preprinta i prohodyat etap recenzirovaniya Protivovirusnye sredstva Razrabotka protivovirusnyh sredstv predpolagaet preryvanie replikacii virusa na kakom libo iz etapov ego zhiznennogo cikla pri etom ne unichtozhaya sami kletki chelovecheskogo tela Virusy bystro razmnozhayutsya chasto mutiruyut i legko adaptiruyutsya razvivaya v konechnom itoge nechuvstvitelnost k lekarstvam i vakcinam Po etoj prichine razrabotka protivovirusnyh sredstv ochen zatrudnena Vedutsya klinicheskie ispytaniya razlichnyh protivovirusnyh sredstv Soglasno sistematicheskomu obzoru ot yanvarya 2022 goda nekotorye antivirusnye sredstva mogut uluchshat klinicheskie ishody u pacientov odnako ni odno ne pokazalo effektivnosti po chasti snizheniya smertnosti Immunomodulyatory Sredstva protiv sindroma vysvobozhdeniya citokinov Sm takzhe Sindrom vysvobozhdeniya citokinov Tocilizumab i sarilumab yavlyayutsya immunosupressorami ingibiruyut interlejkin 6 primenyayutsya pri revmatologicheskih narusheniyah i v lechenii citokinovogo shtorma V sluchae COVID 19 ispytyvayutsya na vozmozhnost snizheniya vyzyvaemogo virusom citokinovogo shtorma i umensheniya riska oslozhnenij Odnako reshenie o primenenii immunosupressorov yavlyaetsya slozhnym i predpolagaet prinyatie vzveshennogo resheniya s uchyotom preimushestv protivovospalitelnogo dejstviya i negativnogo effekta ot vmeshatelstva v rabotu immunnoj sistemy Protiv citokinovogo shtorma ispytyvayutsya i drugie preparaty Predvaritelnye vyvody v nebolshom retrospektivnom obzore lecheniya 21 pacienta tocilizumabom predpolagali bystroe uluchshenie sostoyaniya tyazhelo i kriticheski bolnyh pacientov Randomizirovannoe slepoe ispytanie tocilizumaba sredi bolnyh s gipervospalitelnymi sostoyaniyami pokazalo otsutstvie effektivnosti kak v snizhenii smertnosti tak i v predotvrashenii intubacii odnako nekotorye otlichiya po sravneniyu s gruppoj placebo byli Drugie dva randomizirovannyh issledovaniya pokazali vozmozhnoe snizhenie riskov neobhodimosti ventilyacii lyogkih i smerti po hodu techeniya zabolevaniya no na konechnoj vyzhivaemosti tocilizumab ne skazalsya Dannye issledovaniya RECOVERY pokazali chto vvedenie tocilizumaba v dopolnenie k terapii deksametazonom gospitalizirovannym pacientam na kislorode dopolnitelno snizhaet risk smerti na 14 a prodolzhitelnost prebyvaniya pacientov v bolnice na 5 polnyh dnej Interferony V nachale pandemii provodilis issledovaniya s sistematicheskim ispolzovanie interferonov bolee pozdnie zhe issledovaniya ne smogli prodemonstrirovat effektivnosti interferonov a nekotorye issledovaniya predpolozhili vozmozhnyj vred pri primenenii v tyazhyolyh sluchayah zabolevaniya Provodimye na rannem etape pandemii issledovaniya po primeneniyu interferona alfa nebolshie i ne pozvolyayut delat kakie libo vyvody o vozmozhnosti ego primeneniya Interferony alfa i beta ne rekomenduyutsya k primeneniyu za isklyucheniem kontroliruemyh ispytanij Drugie immunoterapii Monoklonalnye antitela Monoklonalnye antitela predstavlyayut soboj potencialnyj sposob passivnoj immunizacii oni mogut svyazyvatsya s shipovidnymi belkami virusa nejtralizuya ego i prepyatstvuya ego vhozhdeniyu v kletki organizma V to vremya kak vakciny yavlyayutsya luchshim sredstvom profilaktiki monoklonalnye antitela mogut okazatsya poleznymi dlya opredelyonnyh uyazvimyh grupp naseleniya naprimer v sluchayah kogda pacienty vhodyat v gruppy riska i ne byli vakcinirovany ili esli oni zaboleli v period posle vakcinacii kogda immunitet eshyo ne uspel sformirovatsya Nedostatkom monoklonalnyh antitel yavlyaetsya to chto oni mogut dat lish vremennuyu zashitu i zatratny v proizvodstve Sredi grupp riska v lyogkih i srednetyazhyolyh sluchayah kogda vysok risk gospitalizacii VOZ rekomenduet primenenie monoklonalnyh antitel V 2021 godu rekomendovalsya kazirivimab imdevimab v 2022 godu k rekomendaciyam dobavilsya alternativnyj preparat sotrovimab Sredstva ot giperkoagulyacii COVID 19 mozhet vyzyvat razlichnye narusheniya svyazannye s tromboemboliej Antikoagulyanty ispolzuyutsya v lechenii i predotvrashenii podobnyh narushenij Pri koagulopatiyah svyazannyh s COVID 19 chasto primenyayut terapiyu antikoagulyanami chashe vsego ispolzuetsya geparin pri etom neredko soobshaetsya o geparinom inducirovannoj trombocitopenii Poskolku intensivnaya terapiya antikoagulyantami mozhet privodit k krovotecheniyam risk tromboticheskih narushenij sam po sebe ne yavlyaetsya opravdaniem dlya ispolzovaniya dannogo vida terapii Sushestvuyushie rukovodstva opirayutsya v osnovnom na ekspertnye mneniya i mogut znachitelno otlichatsya drug ot druga v tom chisle po profilaktike ili lecheniyu odnako v odnom eksperty shodyatsya v neobhodimosti kachestvennyh randomizirovannyh ispytanij dlya opredeleniya podhodyashej dozirovki v sluchayah COVID 19 Retrospektivnyj analiz 2773 pacientov s COVID 19 pokazal znachitelnoe snizhenie vnutribolnichnoj smertnosti sredi bolnyh kotorym trebovalas mehanicheskaya ventilyaciya lyogkih esli im naznachalas terapiya antikoagulyantami Randomizirovannoe issledovanie REMAP CAP bylo dosrochno prekrasheno i pokazalo obratnye rezultaty dlya pacientov s tyazhyolym sostoyaniem kotorym trebovalas intensivnaya terapiya lechenie antikoagulyantami ne vliyalo na ishody no privodilo k krovotecheniyam Nekotorye rukovodstva predlagayut ispolzovat antikoagulyanty dlya profilaktiki tromboobrazovaniya sredi pacientov s COVID 19 odnako po sostoyaniyu na nachalo oktyabrya bylo nedostatochno dokazatelstv dlya opredeleniya sootnosheniya vozmozhnyh riskov i polzy sredi gospitalizirovannyh pacientov Sravnenie COVID 19 s grippomRazmeshenie v avtorefrizherator v Hakensake umershih ot COVID 19 Virusy grippa i COVID 19 rasprostranyayutsya melkimi kaplyami voznikayushimi pri kashle chihane ili razgovore posle chego kapli mogut popast v nos ili rot nahodyashihsya poblizosti lyudej ili mogut popast v lyogkie na vdohe pri osedanii na predmetah virus mozhet byt zanesyon takzhe kontaktnym putyom pri posleduyushem prikosnovenii k nosu rtu ili glazam V sluchae grippa vazhnuyu rol igraet rasprostranenie bolezni sredi detej a COVID 19 zarazhaet prezhde vsego vzroslyh ot kotoryh uzhe zarazhayutsya deti kak pokazyvayut predvaritelnye dannye obsledovaniya kitajskih domohozyajstv Zabolevaniya razlichayutsya po kontagioznosti pri sezonnom grippe ot odnogo bolnogo zarazhayutsya primerno 1 3 cheloveka indeks reprodukcii R 1 28 pri COVID 19 bolnoj rasprostranyaet zabolevanie na 2 2 5 cheloveka Simptomy u zabolevanij shozhie no pri COVID 19 mozhet voznikat poterya obonyaniya ili vkusa pri grippe zhe poterya obonyaniya ili vkusa obychno ne proishodit Problemy s dyhaniem mogut byt pri oboih zabolevaniyah no pri grippe oni menee veroyatny i associiruyutsya s pnevmoniej Pri COVID 19 vozmozhen ponizhennyj uroven kisloroda dazhe pri bessimptomnom techenii zabolevaniya Oba zabolevaniya mogut protekat kak v lyogkoj tak i v tyazhyoloj forme inogda privodya k smertelnym ishodam Pri oboih zabolevaniyah vozmozhny razlichnye oslozhneniya nachinaya ot pnevmonii i dyhatelnoj nedostatochnosti i zakanchivaya poliorgannoj nedostatochnostyu i sepsisom no v sluchae COVID 19 mogut obrazovyvatsya sgustki v venah i arteriyah lyogkih serdca nog i mozga a u detej est risk vozniknoveniya multisistemnogo vospalitelnogo sindroma V sluchayah oboih zabolevanij v gruppah riska nahodyatsya pozhilye lyudi i lyudi s soputstvuyushimi zabolevaniyami no pri grippe v gruppu riska takzhe vhodyat deti Pomimo porazheniya lyogkih pri COVID 19 vyshe risk disfunkcii drugih organov sredi kotoryh po znachimosti vydelyayutsya pochki vozmozhny takzhe dlitelnye posledstviya i zabolevaniya trebuyushie postoyannogo lecheniya V sluchayah COVID 19 risk gospitalizacii i smerti vyshe chem pri grippe osobenno u lyudej vhodyashih v gruppy riska a takzhe vyshe zatraty na sistemu zdravoohraneniya V oboih sluchayah lechenie napravleno na oblegchenie simptomov a v tyazhyolyh sluchayah mozhet potrebovatsya gospitalizaciya i podderzhivayushee lechenie naprimer mehanicheskaya ventilyaciya lyogkih COVID 19 neredko pytayutsya sravnivat s grippom odnako nakaplivayushiesya nauchnye dannye pokazyvayut chto COVID 19 opasnee grippa dlya gospitalizirovannyh pacientov Terminologiya11 fevralya 2020 goda Vsemirnaya organizaciya po zdravoohraneniyu dala zabolevaniyu oficialnoe nazvanie COVID 19 Zabolevaniyam vyzyvaemym virusami nazvaniya dayutsya v celyah obespecheniya vozmozhnosti obsuzhdeniya rasprostraneniya sposobov peredachi profilaktiki tyazhesti zabolevaniya i metodov lecheniya COVID 19 sokrashyonno ot COronaVIrus Disease zabolevanie vyzvannoe koronavirusom V etom nazvanii SO oznachaet korona corona VI virus virus D bolezn disease a 19 god v kotorom bylo vyyavleno vpervye zabolevanie soobsheno v VOZ 31 dekabrya 2019 goda Virus zhe vyzyvayushij zabolevanie nazyvaetsya po drugomu SARS CoV 2 Takoe nazvanie dano poskolku virus geneticheski shozh s virusom SARS CoV kotoryj v 2003 godu byl otvetstvenen za vspyshku tyazhyologo ostrogo respiratornogo sindroma v Kitae Odnako chasto ispolzuyutsya formulirovki virus COVID 19 koronavirusnaya infekciya COVID 19 ili virus vyzyvayushij COVID 19 Tem ne menee nazvanie zabolevaniya ne yavlyaetsya nazvaniem virusa i ne prednaznacheno dlya zamesheniya nazvaniya SARS CoV 2 dannogo Mezhdunarodnym komitetom po taksonomii V russkom yazyke takzhe upotreblyaetsya nazvanie kovid Ono stalo populyarnym vo vtoroj volne pandemii chastichno vytesniv ispolzovavsheesya nespecialistami vo vremya pervoj volny slovo koronavirus dlya oboznacheniya zabolevaniya Vposledstvii slovo kovid privelo k slovoobrazovaniyu s poyavleniem takih slov kak kovidnyj kovidnik kovidiot i kovidarij Lingvist Maksim Krongauz otmechaet chto nesmotrya na otsutstvie slova v slovaryah obshego naznacheniya ego mozhno ispolzovat rukovodstvuyas uzusom to est slovoupotrebleniem DezinformaciyaOsnovnaya statya Konspirologicheskie teorii o pandemii COVID 19 Posle pervonachalnoj vspyshki COVID 19 mistifikacii i dezinformaciya otnositelno proishozhdeniya masshtabov profilaktiki lecheniya i drugih aspektov zabolevaniya bystro rasprostranilis v internete Dezinformaciya mozhet stoit chelovecheskih zhiznej Otsutstvie dostatochnogo urovnya doveriya i dostovernoj informacii mozhet negativno skazatsya na diagnostike a kampanii po immunizacii naseleniya mogut ne dostignut 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