Wednesday, February 01, 2017

Germany: RKI Risk Assessment On H7N9 In China


Last week we saw a small avalanche of risk assessments released by world public health agencies over the growing number of H7N9 infections being reported in China this winter.   A few examples include:
Updated CDC Assessment On Avian H7N9 
ECDC RRA: Human Infection With Avian Influenza A(H7N9) Virus, Fifth Update 
WHO H7N9 Risk Assessment - Jan 2017

While we are still fairly early in China's `high season' for bird flu, and our information is most certainly incomplete, already we've seen in excess of 240 cases reported in the past 12 weeks.  Roughly double the number of cases reported in the prior 12 months.

While infections are up, so far we haven't seen any evidence of sustained human-to-human transmission.  A few small clusters, but nothing that shouts enhanced transmissibility.  While reassuring, the CDC recently noted that:
. . .  of the influenza viruses rated by the Influenza Risk Assessment Tool (IRAT), H7N9 is ranked as having the greatest potential to cause a pandemic, as well as potentially posing the greatest risk to severely impact public health.

Today Germany's Robert Koch Institute (RKI) weighs in with their own risk assessment - which while stating the risk of seeing imported cases in Germany is low  - provides case definitions and procedures for doctors to follow when treating patients with recent travel to China. 

I've only included some (translated) excerpts.  Click the link below to access the full report, including an extensive list of links.

The RKI to human disease cases with avian influenza A (H7N9)
Stand: 1.2.2017

End March 2013 reported the World Health Organization (WHO) for the first time on the occurrence of a new avian influenza virus A (H7N9) in three patients in eastern China. Until 24 January 2017 more than 1,000 people with A (H7N9) have demonstrably infected, most of them in China. So far at least 350 people have died (Source: European Centre for Disease Prevention and Control (ECDC), see link below). Individual cases were from China to Hong Kong, Macao, Taiwan, Canada (see link below) and Malaysia imported.

The infections occur in waves, each in the winter months. According to WHO and ECDC there since October 2016 already significantly more cases than in the disease waves 2014/15 and 2015/16 total. However, there is so far no evidence that the disease had changed. The majority of cases goes on contacts with poultry or back from visiting poultry markets. Therefore, the Chinese health authorities also take appropriate measures such as the closure of poultry markets. A transmission from human to human has been previously observed only in individual cases; the WHO, currently finds no sustained human-to-human transmission instead (see link below).

The current state of illness and deaths from influenza virus A (H7N9) and current situation reports and risk assessments are available on the website of the WHO and ECDC. They are also regularly in the weekly reports of the ECDC to infectious diseases, and influenza-weekly reports of RKI published (see links below).

Many patients who have been infected with A (H7N9), suffering from severe pneumonia. The symptoms include fever, a one symptoms of upper respiratory tract and shortness of breath. It has also been reported cases of illness with lighter symptoms. The lethality of A (H7N9) infection is, according to the ECDC date depending on the disease shaft between 32% and 44%. She has not changed significantly in recent years.

The ECDC recommends travelers to the affected areas of China to refrain from visiting poultry markets and -farmen to avoid contact with poultry and to take only sufficiently cooked foods to be. The current increase in A (H7N9) infections in China may also individual cases could be imported into Europe; However, the risk of further spread in Europe is estimated to be low.

Single imported cases (for example, by returning travelers from China, which have become infected there with influenza A (H7N9)) can not be ruled out in Germany. Therefore doctors patients who present with an acute respiratory symptoms, after a trip to China in the last ten days should ask before disease onset. Above all, the stay in China in one of the provinces where human cases of influenza A (H7N9) have been reported, the occasion should be a more accurate travel history give (started in Deutsches Ă„rzteblatt from 10/05/2013: "Avian influenza A (H7N9): The potential risk is low but not zero ", see link below).

in particular the following points are relevant for doctors in Germany:
  • RKI guide for physicians to diseases caused by zoonotic influenza viruses (see link below)
  • Case definition for case-finding, reporting and transmission of respiratory diseases associated with influenza A (H7N9) (see link below)
  • Information and recommendations of the German Society for Pneumology and Respiratory Medicine eV and the Paul Ehrlich Society for Chemotherapy eV to the outbreak of influenza A (H7N9) virus infection in humans (see link below)
  • In severe pneumonia and respiratory distress syndrome should (also independent of a travel history) always be a laboratory diagnosis. If influenza is detected, the virus should be typed and subtyped influenza A. Remains subtyping proving the seasonal circulating influenza A subtypes A (H1N1) pdm09 and A (H3N2) is unsuccessful, the patient material or remanufactured sample should be sent as soon as possible for further characterization to the National Reference Centre for Influenza (link to the "Warnings for laboratory diagnostics in patients with suspected influenza a (H7N9) virus infection, "see below).
  • Cluster of severe respiratory disease should be assayed for reasons. This concerns in particular the increased occurrence of diseases in hospitals. Standard measures of infection control should be adhered to (link to the hygiene recommendations of RKI see below).
  • Suspected cases of influenza A (H7N9) are due to the mandatory reporting of zoonotic influenza (Regulation from 1 May 2016) in accordance with § 6 para. 1 IfSG be reported and, in accordance with § 12 IfSG (see case definition).
  • For established and stationary employed doctors and health authorities, the Robert Koch Institute also has recommendations for reporting and management of individuals with suspected influenza A (H7N9) published (see link below).
The WHO has published on its website answers to frequently asked questions on this subject, which also hints infection prevention are listed (see link below). The Foreign Office, which informs in general on its website about medical risks abroad, offers travelers a leaflet on avian influenza at (see link below).

(Continue . . . )

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