Friday, October 10, 2014

EID Journal: Avian Influenza (H7N9) Virus Infection in Chinese Tourist in Malaysia, 2014


Itinerary Of Chinese Tourist With H7N9 In Malaysia – Feb 2014


# 9176


Last February, in Malaysia Reports Their 1st Imported H7N9 Case & Malaysian MOH Statement On Imported H7N9, we looked at the third country (or autonomous region) to see an imported case of human H7N9 infection (the other two being Taiwan and Hong Kong) from Mainland China.


The patient – a 66 year-old woman - had purchased 3 chickens from a live market in Guangzhou, Guangdong Province, China on January 30th, which she slaughtered and cooked. She became mildly symptomatic and saw a doctor prior to departure, but was not tested for the H7N9 virus, and arrived in Malaysia on February 4th.

Her condition deteriorated as she traveled to three different cities in Malaysia, and on the 7th, she sought care at Tuaran District Hospital. She was intubated and transferred to another hospital in Kota Kinabalu, Sabah, Malaysia, where she would receive intensive medical care for the next month. 


Her case illustrates that even in the midst of an avian flu outbreak (the second in two winters) in China, a symptomatic person with recent live poultry exposure was able to board a plane and travel to another country.

As H7N9 isn’t – at this time – easily transmitted between humans, it isn’t a surprise that no additional cases were attributed to exposure to this patient.  But as this virus continues to evolve, there are no guarantees our luck will hold. Last June, in Eurosurveillance: Genetic Tuning Of Avian H7N9 During Interspecies Transmission, we saw the following assessment of the risks from future mutations.


Overall, due to the genetic tuning procedure, the potential pandemic risk posed by the novel avian influenza A(H7N9) viruses is greater than that of any other known avian influenza viruses. A response to this threat requires the combined effort of different sectors related to human health, poultry and wild birds, as well as vigilance and co-operation of the world.


Yesterday, the EID Journal published a review of this imported case to Malaysia, providing considerable details on both this patient’s movements, complicated course of illness, and ultimately successful treatment.  This case also illustrates just how easily an emerging – and potentially dangerous – virus can be transported anywhere in the world in a matter of hours via our increasingly mobile society.



Avian Influenza (H7N9) Virus Infection in Chinese Tourist in Malaysia, 2014

Timothy William, Bharathan Thevarajah, Shiu Fee Lee, Maria Suleiman, Mohamad Saffree Jeffree, Jayaram Menon, Zainah Saat, Ravindran Thayan, Paul Anantharajah Tambyah, and Tsin Wen YeoComments to Author 


Of the ≈400 cases of avian influenza (H7N9) diagnosed in China since 2003, the only travel-related cases have been in Hong Kong and Taiwan. Detection of a case in a Chinese tourist in Sabah, Malaysia, highlights the ease with which emerging viral respiratory infections can travel globally.


Of the ≈400 cases of human avian influenza (H7N9) infection diagnosed in China since 2003, the only travel-related cases were in Hong Kong and Taiwan, which have close geographic, economic, and cultural ties to China and extensive bidirectional travel. This case highlights the ease with which emerging viral infections can travel globally. On a map of recent air travel from China, major destinations identified (12) were Taiwan, Hong Kong, Malaysia, and Singapore; dozens of flights went to major cities in Europe and North America, which received hundreds of visitors directly from China weekly. In the first 3 quarters of 2013, an estimated 72.5 million tourists left China (13). To ensure accurate identification and appropriate management of emerging novel respiratory viral infections, clinicians in destination countries need to obtain detailed travel histories from tourists and returning travelers

The influenza (H7N9) virus is not easily transmissible among humans, and our investigations did not find any evidence of spread to the patient’s fellow travelers, medical staff, or other contacts. However, the virus has the potential to adapt to mammalian hosts over time (14,15). Clinicians and public health authorities need to be alert to the latest epidemiologic information on emerging respiratory viruses; local capacity to isolate, diagnose, and treat illness in travelers with unusual respiratory viral infections is also needed.



It is worth noting that we saw a similar occurrence last January when Canada saw North America’s first imported (and ultimately, fatal) case of H5N1 (see CDC HAN Advisory On Canadian H5N1 Case). 


Again, no forward transmission of the virus was detected.  But as with H7N9, H10N8, H5N6 and many other novel viruses out there, they all are subject to evolutionary changes, and all carry some possibility of adapting better to humans over time.


Which is why we watch these viruses closely for any signs of change.  Earlier this year, we looked at an assessment by the Director Of National Intelligence who includes emerging infectious diseases and Influenza Pandemic As A National Security Threat.

From that report:

Worldwide Threats Assessment – published January 29th, 2014,


Health security threats arise unpredictably from at least five sources: 

  • the emergence and spread of new or reemerging microbes;
  • the globalization of travel and the food supply;
  • the rise of drug-resistant pathogens;
  • the acceleration of biological science capabilities and the risk that these capabilities might cause inadvertent or intentional release of pathogens; and
  • adversaries’ acquisition, development, and use of weaponized agents. 

Infectious diseases, whether naturally caused, intentionally produced, or accidentally released, are still among the foremost health security threats.  A more crowded and interconnected world is increasing the opportunities for human, animal, or zoonotic diseases to emerge and spread globally.  Antibiotic drug resistance is an increasing threat to global health security.  Seventy percent of known bacteria have now acquired resistance to at least one antibiotic, threatening a return to the pre-antibiotic era.

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