Hong Kong CHP Notified Of An H7N9 Case In Anhui Province

          

 

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Occasional H7N9 case reports continue to filter in from Mainland China (Jiangxi Province reported a case on Saturday), but past 60 days has seen unexpectedly low numbers. Reporting from many provinces, however, has not as timely or a detailed as we’d like, leaving some doubt as to whether we are seeing the whole picture.

 

We may yet get another round of `bulk’ H7N9 announcements  from the EOM epidemiological reports filed by the individual provinces near the middle of this month, but this year’s epidemic seems to be winding down.

 

That said, we’ve another H7N9 report  - this time from Anhui Province – published by the Hong Kong Centre for Health Protection.

 

CHP closely monitors additional human case of avian influenza A(H7N9) in Anhui

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (May 6) closely monitoring an additional human case of avian influenza A(H7N9) in Anhui, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the Health and Family Planning Commission of Anhui Province, the male patient aged three in Huaibei had mild symptoms and was in stable condition. He had poultry exposure before onset.

From 2013 to date, 636 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities. Regarding the third wave in the Mainland since November 2014, a total of 196 cases have been reported, including 72 in Guangdong (see attachment for geographical distribution), 39 in Fujian, 38 in Zhejiang, 17 in Jiangsu, eight in Anhui, seven in Xinjiang, six in Shanghai, three in Jiangxi, two in Hunan, two in Shandong, one in Guizhou and one in Hubei.

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The tally of  636 mainland cases provided by the CHP above represents only the `sickest of the sick’ – those ill enough to seek medical care and deemed ill enough to be tested for the virus.

 

Since H7N9 is capable of producing a broad range of symptoms in humans – ranging anywhere from asymptomatic or mild to severe pneumonia – the big unknown is how many cases go undetected in the community. 

 

As with any disease, conventional surveillance and reporting can only reveal the tip of the pyramid. 

Credit CDC

  

Despite their obvious limitations, passive surveillance systems can often tell us if an outbreak is trending up or down  - or spreading to new geographic areas - and it affords an opportunity for epidemiologists to test contacts of known cases to look for signs of human-to-human transmission.

HK CHP Notified Of An Additional Mainland H7N9 Case

Location of Jiangxi Province – Wikipedia

 

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Despite the abrupt slowdown in H7N9 reporting out of China beginning the first week of March (see H7N9: No News Is . . . . Curious), the Mainland has still managed to post nearly 200 cases since November of 2014.  Based on limited, and often delayed reporting to date, this third wave appears to have been less active than the 2nd wave.

 

Note: Many provinces have elected tor release bulk information in EOM epidemiological reports, and it is possible we’ll see additional `April’ cases announced over the next couple of weeks.

 

In the meantime, we’ve got this announcement from Hong Kong’s CHP of their notification of a single H7N9 case in Jiangxi province. 

 

CHP closely monitors additional human case of avian influenza A(H7N9) in Mainland

May 2, 2015 Issued at HKT 18:09

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (May 2) closely monitoring an additional human case of avian influenza A(H7N9) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the Health and Family Planning Commission of Jiangxi Province, the patient is a 39-year-old woman who is hospitalised for treatment in critical condition.

From 2013 to date, 635 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities. Regarding the third wave in the Mainland since November 2014, a total of 195 cases have been reported, including 72 in Guangdong , 39 in Fujian, 38 in Zhejiang, 17 in Jiangsu, seven in Anhui, seven in Xinjiang, six in Shanghai, three in Jiangxi, two in Hunan, two in Shandong, one in Guizhou and one in Hubei.

"Locally, we will remain vigilant and work closely with the World Health Organization and relevant health authorities to monitor the latest developments," a spokesman for the DH said.

The DH's Port Health Office conducts health surveillance measures at all boundary control points. Thermal imaging systems are in place for body temperature checks on inbound travellers. Suspected cases will be immediately referred to public hospitals for follow-up.

The display of posters and broadcast of health messages in departure and arrival halls as health education for travellers is underway. The travel industry and other stakeholders are regularly updated of latest information.

Travellers, especially those returning from avian influenza-affected areas with fever or respiratory symptoms, should immediately wear masks, seek medical attention and reveal their travel history to doctors. Healthcare professionals should pay special attention to patients who might have had contact with poultry, birds or their droppings in affected areas.

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HK CHP Avian Flu Report: 2 Weeks Without An H7N9 Case Report

 

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Compared to the first two waves of H7N9 in China, where we saw daily reports from affected provinces which included both case counts and rudimentary epidemiological information, this year’s reporting has been less detailed and far more haphazard. 

 

Some provinces have just reported an aggregate total in their end of month infectious disease reports, while others have dumped `bulk’ case announcements at irregular intervals (see Jiangsu Province’s Uncertain H7N9 Count).

 

All of which has made it very difficult to compare this year’s outbreak to previous years. As I mentioned last week, in H7N9: No News Is . . . . Curious, for the past couple of weeks H7N9 case reporting has gone strangely silent.   As the first two H7N9 waves didn’t end until May, an abrupt halt in case in early March is unexpected.

 

Today, Hong Kong’s CHP has published their latest Avian Influenza Report, and for the second week in a row, confirm that no new H7N9 cases have been reported by the Chinese Mainland since March the 9th.  

 

Avian Influenza Report (Volume 11, Number 12 (Week 12))

Summary

1. There were no new human cases of avian influenza A(H5N1) reported by the World Health Organization (WHO)#. One new human case of avian influenza A(H5N1) involving a 34-year-old man from Yunnan Province was reported by the National Health and Family Planning Commission (NHFPC) on March 23, 2015.

2. From 2010 to 2014, 32 to 62 confirmed human cases of avian influenza A(H5N1) were reported to WHO annually (according to onset date). In 2015 (as of March 23, 2015), 89 cases were reported by WHO* and two additional cases were reported by NHFPC.

3. Since the previous issue of Avian Influenza Report, there were no new human cases of avian influenza A(H7N9). Since March 2013 (as of March 23, 2015), there were a total of 638 cases reported.

 

It is certainly possible that fewer infections are being recorded this winter, and interventions such as the closing of live poultry markets have dramatically reduced transmission.  It is also worth noting that more spring-like weather has returned to many areas of Eastern China over the past several weeks, which could be a mitigating factor.

 

But this precipitous drop in reporting also comes – perhaps coincidentally – at the same time we saw a major study appear in the Journal Nature  (see Dissemination, Divergence & Establishment of H7N9 In China) warning that the H7N9 virus was evolving rapidly, and that it posed a growing pandemic threat.

 

China is, of course, required to notify the World Health Organization of new H7N9 cases under the terms of the IHR, but how and when they choose to publically disclose case information – even to Hong Kong’s CHP - is pretty much up to them. 

If we are truly seeing a less active, and truncated H7N9 wave, then that would be good news indeed.  But the inconsistent reporting out of China these past few months makes it difficult to assume the best based simply on the absence of data.

HK CHP Notified Of 3 New H7N9 Cases In Guangdong, 2 In Anhui

 

 

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For reasons we can only speculate on - except for Guangdong Province – Mainland China has been very slow to report H7N9 cases this winter.  We’ve seen some batch announcements - often buried in end-of-month provincial statistical reports - but daily reporting has been rare.

 

Of the 16 provinces that have  reported cases during the first two waves, only about half of those have reported cases this winter.

 

While it is possible that H7N9 activity has diminished greatly across the region, when you figure in the irregular reporting, it does stretch credulity a bit. The point being that the numbers we are seeing posted by Hong Kong’s CHP may under-reflect the level of activity across the mainland during this third wave.

That said, we’ve two updates from the Centre For Health Protection, describing 5 new cases.

 

CHP closely monitors three additional human cases of avian influenza A(H7N9) in Mainland

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (February 25) closely monitoring three additional human cases of avian influenza A(H7N9) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the notification of the Health and Family Planning Commission (HFPC) of Guangdong Province, the male patient aged 59 in Zhaoqing was hospitalised for management in critical condition.

In addition, according to the HFPC of Anhui Province, the two male patients aged 48 and 75 with poultry exposure before onset were hospitalised for management. Both were in critical condition.

To date, 585 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities in Guangdong (172 cases), Zhejiang (156 cases), Jiangsu (70 cases), Fujian (58 cases), Shanghai (45 cases), Hunan (24 cases), Anhui (19 cases), Xinjiang (10 cases), Jiangxi (nine cases), Shandong (six cases), Beijing (five cases), Henan (four cases), Guangxi (three cases), Jilin (two cases), Guizhou (one case) and Hebei (one case).

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CHP notified of two additional human cases of avian influenza A(H7N9) in Guangdong

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (February 25) closely monitoring two additional human cases of avian influenza A(H7N9) in Guangdong notified by the Health and Family Planning Commission of Guangdong Province (GDHFPC), and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the GDHFPC, a male patient aged 3 in Heyuan and a female patient aged 18 in Foshan were hospitalised for treatment, and are in a stable and critical condition respectively.

To date, 587 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities in Guangdong (174 cases), Zhejiang (156 cases), Jiangsu (70 cases), Fujian (58 cases), Shanghai (45 cases), Hunan (24 cases), Anhui (19 cases), Xinjiang (10 cases), Jiangxi (nine cases), Shandong (six cases), Beijing (five cases), Henan (four cases), Guangxi (three cases), Jilin (two cases), Guizhou (one case) and Hebei (one case).

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Even the best surveillance and reporting will fail to detect cases, and those who end up tested and counted are almost always the sickest of the sick – the ones who are sickened enough to go to the hospital.   

Mild and moderate cases are very likely to go uncounted.

In Lancet: Clinical Severity Of Human H7N9 Infection we saw a study that proposed, after roughly 130 cases were confirmed in the spring of 2013, that:

 

Our estimate that between 1500 and 27 000 symptomatic infections with avian influenza A H7N9 virus might have occurred as of May 28, 2013, is much larger than the number of laboratory-confirmed cases.

 

How accurate these estimates are is unknown, but any official case count almost certainly under-represents the real burden of H7N9, perhaps by a sizable margin.