China’s MOA: H7N9 Fatalities Higher Than Previously Announced

 

Credit Dr. Ian Mackay VDU Blog

 

 

 

# 8317

 

 

Although China has been refreshingly open about announcing new H7N9 cases over the past year, one area where it has been difficult to keep track has been patient outcomes.  Often patients are hospitalized in critical condition for weeks, or even months, and only rarely do we get an update as to whether they were discharged or died.

 

A little over a week ago, Dr. Ian Mackay looked at the number of fatal outcomes in H7N9 snapdate; the number of surviving and fatal human cases.…, and discussed the variable numbers we’ve seen coming from the individual Provinces and the media.

 

Late in January, the ECDC published their 3rd Rapid Risk Assessment on H7N9, where – based on 56 reported deaths out of 251 cases – they estimated a mortality rate of 22.3%.

 

Over the past month we’ve seen roughly 100 more cases reported, and an extrapolation would put the number of deaths in the upper 70s,  but today we learn from China’s Ministry of Agriculture that the number of deaths is quite a bit higher.

 

A big hat tip goes to Tetano and Sharon Sanders on FluTrackers for picking up a pair of reports (one directly from the MOA) indicating that – so far – H7N9 has resulted in 347 reported cases and 109 deaths.

A (tentative) CFR closer to  31.4%  - or 40% higher than previously disclosed.

 

This from the Chinese MOA’s General Office of the Ministry of Agriculture to seek "national poultry H7N9 influenza eradication program (draft)" opinion letter:

 

Office of the Ministry of Agriculture

February 19, 2014

National Poultry H7N9 influenza eradication program

To further improve the people infected with H7N9 avian influenza outbreak response work, to discover, excluding H7N9 avian influenza virus, and effectively protect poultry production safety, animal product quality and safety and public health and safety, according to the "Animal Epidemic Prevention Law" and other laws and regulations, the development of this plan.

I. Background

2013 China experienced H7N9 avian influenza confirmed cases since the first case of human infection, infection and disease has caused many deaths. As of February 18, 2014, has a total 347 cases of reported cases and 109 deaths. People infected with H7N9 bird flu on China's poultry industry has brought a serious impact. According to the China Animal Husbandry Association statistics, in the first half of 2013 the poultry industry, the direct loss of $ 60 billion since 2014 has lost 20 billion yuan.

National Avian Influenza Reference Laboratory report, the current environment isolated from poultry and out of the H7N9 avian influenza virus in poultry AVIRULENT performance, but the presence of the virus to mutate into highly pathogenic strains of possibilities, will the poultry industry greater risk. National surveillance and epidemiological findings suggest that, H7N9 avian influenza virus can infected poultry and contaminated the environment in the patient's body to the separation, the current positive samples mainly from the live poultry trade field point, but does not rule out the existence of a small number of contaminated poultry farms .

Developed and implemented national eradication program, quickly take unified action, master virus space, time, inter-group distribution of live poultry trade field points, poultry farms and other key aspects to take timely monitoring Excluding measures to strengthen source control, is significant.

(Continue . . .)

 

The next obvious question – assuming these numbers are right – is: 

 

Has the CFR gone up appreciably during this second wave or has the reporting on fatalities lagged behind all along? 

 

A sudden spike in mortality would be significant, as discussed last week, in Eurosurveillance:The Evolving Threat From New, Reassorted H7N9 Viruses. There we learned of three new reassortant H7N9 viruses detected during this second wave.  The report cautioned:

 

. . .  the new reassortments generated by A(H7N9) and local A(H9N2) strains may produce avian influenza virus strains that are more adaptive and have a higher pathogenicity in humans [16], emphasising the importance of continuously monitoring the A(H7N9) epidemic.

 

Whether today’s revised CFR number is due to a change in the virus’s behavior or simply the result of a long-term lapse in fatality reporting  is too early to know.

But either way, H7N9 deserves our ongoing attention and vigilance.

Hong Kong Hospital Authority On Today’s H7N9 Fatality

 

# 8241

 

In a quick follow up to an earlier report  this morning (see CHP Announces 4th H7N9 Case In Hong Kong), Hong Kong’s Hospital Authority has released the following statement providing a few more details on the presentation and course of treatment of their latest H7N9 case.

 

Tuen Mun Hospital response to media enquiries on confirmed human case of avian influenza A(H7N9)
 

The following is issued on behalf of the Hospital Authority:

In response to media enquiries on a confirmed human case of avian influenza A(H7N9), the Tuen Mun Hospital (TMH) spokesman gave the following reply today (January 29):

A 75-year-old patient with heart disease and other chronic illnesses was sent by ambulance to the Accident and Emergency Department (AED) of TMH at about 9pm yesterday (January 28) for chest pain, shortness of breath and cough. The patient claimed that he had stayed in Shenzhen between January 20 and 26 and had no history of contact with live poultry.

Preliminary examination by AED medical staff found that the patient showed signs of heart failure, fever and pneumonia. The patient was then transferred to a medical ward for follow-up treatment. Physicians subsequently admitted the patient to an isolation ward as further examination indicated that the patient had severe pneumonia apart from the cardiac condition. The hospital also arranged an influenza test for the patient.

The patient's vital signs were stable in the isolation ward. He was prescribed broad-spectrum antibiotics. His condition deteriorated at about 6am this morning and he finally succumbed around 8am. The hospital has referred the case to the Coroner for follow up. Preliminary laboratory results available this afternoon were positive to H7. The results were later confirmed by the Centre for Health Protection of the Department of Health.

The hospital has introduced enhanced cleaning of the related wards and will work closely with the Centre for Health Protection in contact tracing.

Ends/Wednesday, January 29, 2014
Issued at HKT 19:42

 

In a related story, Hong Kong’s SFH (Secretary For Food & Health) Dr. Ko Wing-man made this statement regarding this most recent H7N9 case.

 

Following is the transcript of remarks made by the Secretary for Food and Health, Dr Ko Wing-man, after attending a public function today (January 29):

Reporter: (On measures the Government will take after confirmation of the fourth human case of avian influenza A (H7N9).)

Secretary for Food and Health: This is the fourth case of Hong Kong citizens contracting H7N9 virus after visiting the Mainland, mainly Shenzhen because of the geographical proximity. There is no way that we can stop the human traffic between the Mainland and Hong Kong. There are bound to be many HK citizens paying a visit to the Mainland, so the most important thing is to take precautions. If you are just a visitor to the Mainland, please avoid getting into contact with live poultry or wild birds and avoid visiting or getting close to wet markets with live poultry. If you are living or staying in the affected area for a longer time, and there is no way that you can avoid going to a wet market, then one should adopt more stringent personal protection, such as carrying a mask, and very importantly, washing hands before touching eyes, nose or mouth.

Cambodia MOH Reports 23rd H5N1 Case Of 2013 – Fatal

Credit Wikipedia

 

# 7934

 

 

For the second time in a week (see Cambodia MOH Reports 22nd H5N1 Case Of The Year) we learn of a child infected with the H5N1 virus from the Cambodian Ministry of Health. This time, it is a 2 year-old form Pursat Province, who died on October 26th.

 

Most of Cambodia’s H5N1 activity has been centered this year in the southern provinces (Takeo, Kampong Speu, Kampot, Phnom Penh).  I believe this to be the first case reported from the western province of Pursat, at least over the past several years.

 

To date, Cambodia has reported 44 cases of H5N1 infection, with 23 of those occurring this year.   This from the Ministry of Health.

 

 

23rd New Human Case of Avian Influenza H5N1 in Cambodia in 2013

  
04 November 2013

The Ministry of Health (MoH) of the Kingdom of Cambodia wishes to advise members of the public that one new human case of avian influenza has been confirmed for the H5N1 virus. This is the 23rd case this year and the 44th person to become infected with the H5N1 virus in Cambodia. The 23rd case died on 26th October 2013. Of the 44 confrrmed cases, 33 were children under 14, and 27 of the 44 were female. In addition, only 11 cases out of the 23 cases this year survived.

The 23rd case, a 2-year-old girl from Svay Chrum village, Borng Bort Kandal commune, Bakane district, Pursat province was confirmed positive for H5N1 human avian influenza on 30th October 2013 by Institut Pasteur du Cambodge. The girl developed fever on 17th October 2013. On 19th October 2013, her parents sought treatment for her at a local private practitioner. Her condition worsened and she was admitted to Jayavarman VII Hospital in Siem Reap on 25th October 2013 with fever, running nose, lethargy, dyspnea, cough and breathing difficulties. Laboratory samples were taken the same day, but no Tamifu was administered. The girl died on the 26th October 2013.

(Continue . . . )

While its likely we aren’t getting comprehensive reporting from all of the H5N1 endemic countries around the globe (due to censorship, lack of surveillance, and/or political turmoil), Cambodia – increasingly over the past three years – has grown to become a hotspot for human H5 infection.

2005 – 4 cases                     2010 – 1 case

2006 – 2 cases                     2011 – 8 cases

2007 – 1 case                       2012 - 3 cases

2008 – 1 case                       2013 – 23 cases

2009 – 1 case                      

 

So far, all of the cases this year appear to be widely scattered and have been linked to direct contact to infected poultry. There are no indications of human-to-human spread of the virus.  

 

While we have been preoccupied this summer with H7N9, MERS-CoV, and even a new strain of H7N7 (see Nature: Genesis Of The H7N9 Virus) – H5N1 remains a legitimate concern.  For now, however, H5N1 remains poorly adapted to humans, only causing sporadic infections in Southeast Asia and the Middle East, and is primarily a threat to poultry. 

 

That status could change, of course.

 

So we watch these cases around the world with great interest, looking for any signs that the virus is evolving, and that it is moving towards becoming a bigger public health threat.

UK: NCoV Patient Dies

Coronavirus – Credit CDC PHIL

# 6948

 

Via a brief public announcement from Queen Elizabeth Hospital in Birmingham, England we learn of the death of the second person to be infected in the current UK cluster (see WHO NCoV Update – Feb 16th).

 

This patient was a relative of the man who recently returned from the Middle East infected with the novel coronavirus, and reportedly had non-related immune system issues.

 

Here is the hospital announcement, after which I’ll return with more.

 

 

Novel coronavirus patient dies at QEHB

Story posted/last updated: 19 February 2013

A patient being treated for novel coronavirus at the Queen Elizabeth Hospital Birmingham (QEHB) has died.

 

The patient passed away on Sunday morning in the hospital’s critical care unit. The hospital extends its sympathies to the family.

 

The patient was already an outpatient at QEHB, undergoing treatment for a long-term, complex unrelated health condition. The patient was immuno-compromised and is believed to have contracted the virus from a relative who is being treated for the condition in a Manchester hospital.

 

QEHB is working closely with the Health Protection Agency (HPA) which is currently following up other household members and contacts of this case.

 

QEHB does not intend to hold a press conference or make any of its experts available for interview at this time.

 

 

Of the twelve laboratory-confirmed cases, this marks the sixth fatality. While half of all confirmed cases have now died, it is too soon to assume that this virus carries with it a 50% CFR (Case Fatality Ratio).

 

Reports from the opening Jordan cluster in April of last year suggest that there may have been as many as 11 infections, of which only two were laboratory confirmed. 

 

Add to that the existence of a mild case (#12 lab confirmed) - who isn’t even hospitalized – and simple fact is we don’t have enough quality data yet to determine a reasonable CFR.

 

Until we get a better handle on the true denominator (the total number of infections) and numerator (the actual number of deaths), any CFR estimates made today would have to be based on a good deal of guesswork and assumptions.

 

At this point I think it is fair to say that this virus is capable of producing very severe, even fatal illness, in a significant subset of those it infects. 

 

But whether that subset will ultimately end up being 50%, 33%, or 10% (or perhaps less) of those infected is too soon to tell.

 

Later today, I’ll have eye-opening research from the journal mBio on the affinity of this  NCoV to the human respiratory tract. 

The Return Of Naegleria fowleri

L & R: Trophozoites of N. fowleri in brain tissue, stained with H&E. Center: Ameboflagellate trophozoite of N. fowleri. Credit: DPDx

 

# 6442

 

While it is exceedingly rare, each summer we hear of one or two fatal cases of PAM (Primary Amoebic Meningoencephalitis) here in the United States caused by an infection usually acquired while swimming in warm lakes and streams.

 

Tragically, an 8-year old boy from South Carolina has become the latest victim (see Amoeba kills Sumter youth –The State).

 

Blake Driggers reportedly fell ill a week after swimming in Lake Marion and was rushed to the hospital by his family.

 

Roughly a week later he died. With no effective treatment, survival with this infection is very rare. 

 

Last year, in Sometimes It’s Zebras I wrote about this usually fatal form of meningitis caused by the Naegleria fowleri parasite.

 

N. flowleri is an amoeba, which can often be found in the silt at the bottom of warm water lakes and streams. If absorbed through the nostrils - it can make a beeline towards the brain.

 

Although usually only a danger to swimmers, last year we saw a new wrinkle when 2 people in Louisiana became infected through the introduction of tap water into their sinuses using a neti pot.

 

Photo Credit – Wikipedia Commons

These incidents caused the Louisiana Health Department to recommend that people `use distilled, sterile or previously boiled water to make up the irrigation solution’ (see Neti Pots & Naegleria Fowleri).

 

While it made a lot of headlines, this was not the first time that nasal irrigation has been linked to PAM. Several years ago N. fowleri contaminated tap water in Karachi, Pakistan may have caused 13 cases over 18 months.

 

According to the CDC’s FAQ on Naegleria, we average 2 to 4 infections each year in the United States with this parasite.  They list the common sources of the amoeba as:

Where is Naegleria fowleri found?

Naegleria fowleri is found around the world. In the United States, the majority of infections have been caused by Naegleria fowleri from freshwater located in southern-tier states (2). The ameba can be found in:

• Bodies of warm freshwater, such as lakes and rivers
• Geothermal (naturally hot) water, such as hot springs
• Warm water discharge from industrial plants
• Geothermal (naturally hot) drinking water sources
• Soil
• Swimming pools that are poorly maintained, minimally-chlorinated, and/or un-chlorinated
• Water heaters with temperatures less than 47°C (3, 4)

Naegleria fowleri is not found in salt water, like the ocean.

 

Since millions of people swim in waters where this amoeba naturally occur (or are otherwise exposed) and only a small handful of infections result, the odds of acquiring this infection are extraordinarily low.

 

But the Florida Department of Health has some common sense safety advice on how to avoid this parasite.

 

Photo Credit – Florida DOH

For more information on the Naegleria parasite, you can visit the CDC’s Naegleria webpage.

 

UPDATE:

While I was writing this blog, Ronan Kelly and Alert over at FluTrackers were posting on a recent spate of deaths due to Naegleria – once again in Karachi, Pakistan.

 

The number of deaths being reported varies depending on the source, but the media is reporting between 3 and 8 fatalities over the past couple of weeks. 

 

You can follow the media reports in this thread.