Hong Kong: Steering Committee Reconvenes On H7N9

Dr. Ko Wing-man  SFH

 

 

 

# 8039

 

The nimble-fingered typists at Hong Kong’s Centre for Health Protection are getting a workout today, as we’ve another update on their H7N9 response just posted on their website (see earlier reports HK CHP: Epidemiological Investigation & Response To H7N9 Case, HK: Hospitals Increase Infection Control Efforts Due To H7N9 Concerns, HK CHP: Notification Letter To Doctors On H7N9 Case).

 

Today, Dr. Ko Wing-man - Secretary for Food & Health (SFH) - reconvened the Steering Committee on Serious Response Level under the Preparedness Plan for Influenza Pandemic, which also met yesterday.  First we have some remarks made by the SFH to reporters after this meeting, and then  a summary of the meeting from the CHP.

 

 

SFH on update of the confirmed human case of avian influenza A(H7N9)

Following is the transcript of remarks made by the Secretary for Food and Health, Dr Ko Wing-man, after chairing a meeting of the Steering Committee on Serious Response Level under the Preparedness Plan for Influenza Pandemic this afternoon (December 3):

Secretary for Food and Health: We have convened again a meeting of the Steering Committee on Serious Response Level under the Preparedness Plan for Influenza Pandemic this afternoon. In addition to departments under the Food and Health Bureau, other relevant bureaux and departments also took part in the meeting. At today's meeting, the Hospital Authority provided an update on the clinical condition of the patient who is the first confirmed human case of avian influenza A(H7N9). The patient is still receiving treatment in the Intensive Care Unit of Queen Mary Hospital. Her condition remains critical. The Centre for Health Protection has also updated the meeting on its work on contact tracing.

      
Reporter: (On how long the work on contact tracing will be continued)

Secretary for Food and Health: We would certainly continue the work on contact tracing until all persons, whom we have reasons to suspect that they had contacts with the first confirmed patient of avian influenza A(H7N9) in Hong Kong, have been traced. In this regard, the incubation period of the disease is up to 10 days. In this particular incident, (the incubation period) would be sort of a reference indicator.    
(Please also refer to the Chinese portion of the transcript.)

Ends/Tuesday, December 3, 2013
Issued at HKT 21:24
NNNN

 

Additional details on Hong Kong’s Pandemic Preparedness response comes from the following press release:

 

SFH chairs meeting of steering committee on preparedness plan for influenza pandemic

The Secretary for Food and Health, Dr Ko Wing-man, today (December 3) again convened a meeting of the Steering Committee on Serious Response Level under the Preparedness Plan for Influenza Pandemic to follow up on the latest development of the first confirmed human case of avian influenza A (H7N9) in Hong Kong and relevant contingency measures.

The meeting comprises representatives from the Centre for Health Protection (CHP) of the Department of Health, Hospital Authority (HA), the Food and Environmental Hygiene Department (FEHD), the Agriculture, Fisheries and Conservation Department (AFCD), the Education Bureau (EDB), the Commerce and Economic Development Bureau, Tourism Commission, the Home Affairs Department (HAD), the Information Services Department, the Social Welfare Department and the Leisure and Cultural Services Department (LCSD).

At the meeting, the HA reported on the latest condition of the index patient and other related persons, while the CHP reported on the source of contracting the disease and the tracing of contacts with the patient.

The patient is in critical condition at the Intensive Care Unit of Queen Mary Hospital. The CHP has so far successfully contacted over 200 persons who had contacts with the patient, including 17 persons with close contacts.  Of which, 10 home contacts of the patient were tested negative for the H7N9 virus after rapid test at this stage. Close contacts without any symptoms will be arranged to stay in non-hospitalised quarantine facilities. It is expected that five close contacts without any symptoms will be sent to Lady MacLehose Holiday Village of the LCSD in Sai Kung for quarantine tonight.

The HA has also taken measures in preparation for activation of Serious Response Level in public hospitals and the conduct of rapid test, while its expert group has met to discuss the clinical issues relating to the treatment protocol on H7N9.

The DH would strengthen the port health measures.  Relevant departments will help disseminate information on preventive measures for H7N9 to enhance public awareness.

With regard to imported live poultry, the patient has reportedly visited a live bird market in Shenzhen, slaughtered and cooked a live chicken for consumption.  But details are not available.  As a precautionary measure, we have suspended the import of live poultry from the registered farms in Shenzhen starting from today.  The supply of live poultry in Hong Kong was not affected today.

The FEHD has stepped up cleansing and disinfection of retail outlets for live poultry, as well as enhanced inspection to ensure strict compliance with the rule against overnight stocking of live poultry.  The Department has also disinfected the patient’s residence.

The AFCD has conducted visits to 15 local chicken farms and taken specimens for testing.  No irregularity was detected.  It will conduct visits to the remaining 15 local chicken farms tomorrow.  At the same time, the Department will continue to inspect the poultry wholesale market, Yuen Po Street Bird Garden and pet bird shops etc. to ensure that the birds are in healthy and normal condition.  It has also issued letters to the trade reminding them to stay alert and strictly follow the biosecurity and hygiene measures.  The Department will continue to take samples from dead birds and poultry for testing of avian influenza.

The Government will continue to monitor the situation and maintain transparency in release of information. The CHP has set up a designated website and issued letters to inform the relevant trades the latest information and precautionary measures against the disease through the network of the EDB, the HAD and the Tourism Commission.

The public are reminded to maintain good personal hygiene, wash hands frequently and avoid contacts with birds and poultry, while travelling the public should avoid visit to any poultry markets.  For enquiries, the public can visit the website of CHP or call its hotline (2125 1111) which operates from 9am to 6pm.

Ends/Tuesday, December 3, 2013
Issued at HKT 22:43

HK CHP: Epidemiological Investigation & Response To H7N9 Case

 

# 8037

 

This morning  Hong Kong’s CHP has published a detailed accounting of their epidemiological tracing, and follow up, of contacts of their H7N9 patient this morning, with additional details on their quarantine plans that I blogged about earlier today (see HK: H7N9 Contact Tracing, Testing, Isolation & Quarantine). Among the revelations:

 

The patient’s traveling companion has now been located (see Video: HK Officials Seeking Traveling Companion Of H7N9 Patient), has tested negative, and remains asymptomatic.

At this point more than 200 people with potential exposure have been offered Tamiflu ® prophylaxis, most of whom are medical staff or hospital employees (see H7N9: CDC Guidance On Antiviral Chemoprophylaxis  for additional background).

The CHP is undertaking a massive public awareness campaign on H7N9 prevention.

 

All of which illustrates the seriousness with which Hong Kong’s public health authority is treating this single case.

3 December 2013

Epidemiological investigation and follow-up actions by CHP on confirmed human case of avian influenza A(H7N9) 

A spokesman for the Centre for Health Protection (CHP) of the Department of Health (DH) today (December 3) provided an update on the first confirmed human case of avian influenza A(H7N9) in Hong Kong affecting a woman aged 36.

 

"The Serious Response Level under the Government's Preparedness Plan for Influenza Pandemic has been activated while the CHP's epidemiological investigation and follow-up actions are currently in full swing," the spokesman remarked.

 

As of 2pm today, contact tracing conducted by the CHP has located 17 close contacts and over 200 other contacts. Details are as follows:

 

(A) 17 close contacts of the patient have been quarantined and prescribed with Tamiflu prophylaxis, including:

1. All ten home contacts, including four with non-specific symptoms, have been quarantined in Princess Margaret Hospital (PMH). Their specimens all tested negative for the avian influenza A(H7) virus upon preliminary laboratory testing by the Public Health Laboratory Services Branch (PHLSB) of the CHP;

2. The female travel collateral aged 33 who visited Shenzhen with the patient has been located and has remained asymptomatic. Her specimen tested negative for the avian influenza A(H7) virus upon preliminary laboratory testing by the PHLSB and she was transferred to PMH for quarantine; and

3. Six patients who stayed in the same cubicle with the confirmed patient in Tuen Mun Hospital (TMH) are currently under quarantine in hospital pending laboratory testing.

    The Lady MacLehose Holiday Village in Sai Kung under the Leisure and Cultural Services Department has been converted as quarantine centre and asymptomatic close contacts will be transferred there.

(B) Over 200 other contacts of the patient have been put under medical surveillance and offered with Tamiflu prophylaxis, including:

1. The two private doctors, Dr Simon Wong Siu-shan (Shop 17, G/F, Kai Hei Land Building, 385 Castle Peak Road) and Dr Wong Chun-yan (Shop 102A-103, G/F, Kam Wah Shopping Arcade, Tuen Lung Street), practising in Tuen Mun whom the patient respectively consulted at about 11am on November 25 and around 8.30pm on November 26 have been located. Both doctors, their staff, patients and accompanying relatives (over 30 persons) have all remained asymptomatic; and

2. Over 170 healthcare workers (HCWs) in TMH and QMH and the ambulance officers involved in patient transfer between the two hospitals have been identified. Seven of the HCWs who presented with non-specific symptoms have been tested negative for the avian influenza A(H7) virus.

    Contact tracing by the CHP is ongoing.

    "The CHP has also enhanced surveillance over suspected cases in public and private hospitals starting from today," the spokesman added.

    The CHP has issued letters to doctors and hospitals, kindergartens, child care centres, primary and secondary schools, as well as residential care homes for the elderly and disabled to keep them abreast of the latest situation.

    "The confirmed case has been notified to the World Health Organization, the National Health and Family Planning Commission, the General Administration of Quality Supervision, Inspection and Quarantine of the Mainland as well as health and quarantine authorities of Guangdong, Zhuhai and Macau," the spokesman said.

    "All border control points (BCPs) have implemented disease prevention and control measures. Body temperature checks and health surveillance have been enhanced. The Port Health Office of the DH has maintained liaison with the Shenzhen Entry-Exit Inspection and Quarantine Bureau in paying attention to travellers, and also cross-boundary students, who present with fever or are symptomatic. Suspected cases will be immediately referred to public hospitals for follow-up investigation," the spokesman remarked.

    Regarding health education to travellers at BCPs, distribution of health education pamphlets, the display of posters on avian influenza A(H7N9) in departure and arrival halls, in-flight public announcements, environmental health inspection, and the provision of regular updates to the travel industry via meetings and correspondence have all been escalated.

    The DH will keep a close eye on the latest development and adopt corresponding port health measures.

    The CHP's hotline (2125 1111) has been set up for public enquiries which will operate from 9am to 6pm. As of 4pm today, 13 enquiries were received.

    "Travellers, especially those returning from avian influenza A(H7N9)-affected areas, with fever or respiratory symptoms are reminded to immediately wear facial masks, seek medical attention, and reveal their travel history to doctors. Healthcare professionals should also pay special attention to patients who might have had contact with birds, poultry or their droppings in affected areas," the spokesman advised.

    The spokesman also urged travellers not to visit wet markets with live poultry in the affected areas and to avoid direct contact with poultry, birds and their droppings. If contact has been made, they should thoroughly wash their hands with soap and water.

    Members of the public should remain vigilant and are reminded to take heed of the following preventive advice against avian influenza:

• Poultry and eggs should be thoroughly cooked before eating;
• Wash hands frequently with soap, especially before touching the mouth, nose or eyes, handling food or eating; after going to the toilet or touching public installations or equipment such as escalator handrails, elevator control panels or door knobs; or when hands are dirtied by respiratory secretions after coughing or sneezing;
• Cover the nose and mouth while sneezing or coughing, and hold the spit with a tissue and put it into a covered dustbin;
• Avoid crowded places and contact with fever patients; and
• Wear a mask when respiratory symptoms develop or when taking care of fever patients.

    The public may visit the CHP's avian influenza page (www.chp.gov.hk/en/view_content/24244.html) and its website (www.chp.gov.hk/files/pdf/global_statistics_avian_influenza_e.pdf) for more information on avian influenza-affected are

HK: Hospitals Increase Infection Control Efforts Due To H7N9 Concerns

H7N9 Awareness Campaign Summer 2013 - Photo credit Hong Kong’s CHP

 

# 8036

 

Hong Kong packs a little more than 7 million people into just 426 sq. miles of territory, making it the fourth most densely packed area in the world (cite). Infectious diseases are better able to transmit among humans when population densities are high, and so Hong Kong’s public health sector takes prevention efforts quite seriously. 

 

While only one H7N9 case has been identified in Hong Kong thus far, it isn’t unreasonable to assume there might be others – perhaps only mildly ill – in the region.   For this reason hospitals in Hong Kong are ramping up their alert status, patient triage, and imposing new, strict infection control policies (including requiring masks for all visitors).

 

The following announcement comes from Hong Kong’s Hospital Authority.

 

Serious Response Level activated in public hospitals

 

The following is issued on behalf of the Hospital Authority:

The Hospital Authority (HA) spokesman today (December 3) announced the activation of the Serious Response Level in public hospitals to tie in with the Government's raising of the response level of the Preparedness Plan for Influenza Pandemic from "Alert" to "Serious". The HA Central Committee on Infectious Diseases & Emergency Response held a special meeting this morning to discuss and review thoroughly the contingency measures under the Serious Response Level in public hospitals.

The HA spokesman said front-line hospital staff at Accident and Emergency Departments and general outpatient clinics are reminded to stay vigilant to patients seeking consultation at public hospitals. Enhanced surveillance and patient triage guidelines are in place to ensure timely reporting and early arrangement of clinical tests.

"Under the Serious Response Level, more stringent infection control measures, which include visiting arrangements, are enforced in public hospitals. The visiting arrangements include not allowing visiting at isolation wards unless on compassionate grounds. For general acute wards, visiting hours would be no more than two hours per day with no more than two visitors per visit. For convalescent and infirmary wards, visiting hours would be no more than four hours per day with no more than two visitors per visit."

The spokesman also reminded the public that visitors to public hospitals and clinics are now required to put on surgical masks and perform hand hygiene before and after visiting patient areas.

Furthermore, volunteer services and clinical attachment in public hospitals have been suspended under the Serious Response Level. In regard to personal protection equipment, such as surgical masks and N95 masks, the current stockpile is adequate for three months' consumption. The HA will also maintain close liaison with the suppliers to ensure a sustainable supply. The isolation beds in the seven hospital clusters will be deployed when needed.

According to the spokesman, the HA will continue to closely collaborate with the Centre for Health Protection in monitoring the latest situation and keep the general public as well as health-care workers updated on developments on a regular basis.

Ends/Tuesday, December 3, 2013
Issued at HKT 19:46

 

HK: H7N9 Contact Tracing, Testing, Isolation & Quarantine

 

# 8035

 

Now that Hong Kong’s first (imported) case of H7N9 has been identified, the job of contacting and testing all of her close contacts over the past two weeks becomes paramount for public health officials. Since she is in critical condition, and on an ECMO (Extracorporeal Membrane Oxygenation) machine since November 30th, getting detailed information about her contacts has proven difficult.

 

So far, 200 people have been contacted, and 17 close contacts have been tested (all negative for now).  Those with negative results will be moved from hospital isolation and quarantined at a holiday resort while they are kept under observation.  This from RTHK.

 

Bird flu contacts test negative for H7N9

03-12-2013

The government says 17 people who had close contact with the first Hong Kong person to come down with H7N9 bird flu have all tested negative for the virus.

This includes an Indonesian friend who travelled to Shenzhen with the women, who remains in a critical condition in hospital.

All 10 members of a family whom the sick Indonesian domestic helper worked for and six people who shared the same ward with her in Tuen Mun Hospital have also tested negative.

The Health Secretary, Ko Wing-man says these people have been moved out of hospital isolation wards and will be sent to the Lady McLehose Holiday Village for continued observation.

 

Although they are often used interchangeably in the press, here is how the CDC defines Quarantine and Isolation:

 

The CDC applies the term "quarantine" to more than just people. It also refers to any situation in which a building, conveyance, cargo, or animal might be thought to have been exposed to a dangerous contagious disease agent and is closed off or kept apart from others to prevent disease spread.

The Centers for Disease Control and Prevention (CDC) is the U.S. government agency responsible for identifying, tracking, and controlling the spread of disease. With the help of the CDC, state and local health departments have created emergency preparedness and response plans. In addition to early detection, rapid diagnosis, and treatment with antibiotics or antivirals, these plans use two main traditional strategies—quarantine and isolation—to contain the spread of illness. These are common health care practices to control the spread of a contagious disease by limiting people's exposure to it.

The difference between quarantine and isolation can be summed up like this:

• Isolation applies to persons who are known to be ill with a contagious disease.
• Quarantine applies to those who have been exposed to a contagious disease but who may or may not become ill.

 

Hong Kong has a good deal of experience with both isolation and quarantine procedures, as they were employed extensively more than a decade ago for the SARS epidemic.   During that outbreak, 1,750 Hong Kong residents were infected, 286 died, and thousands were quarantined to prevent its spread (see SARS and Remembrance).

Since a negative quick test is no guarantee that someone who has been exposed isn’t infected (this patient tested negative twice while hospitalized before testing positive on Dec 2nd), it is prudent to try to quarantine those who have been exposed until infection can be ruled out.  Since hospital isolation is overkill for asymptomatic (and likely uninfected) individuals, other arrangements that are reasonably palatable to those quarantined are desirable.

 

To that end, Hong Kong’s CHP has reserved cabins at the Lady McLehose Holiday Village to house those under observation.  The facility is described on Gov HK website as:

 

Located within Sai Kung Country Parks at Pak Tam, Sai Kung, the Lady MacLehose Holiday Village has an air of tranquility and presents a charming view of the woody hillsides. Each bungalow, which can accommodate 3 to 15 persons, is self-contained with a sitting room, bedroom(s) and a toilet with shower facilities. The Camp has a capacity of 280 campers. Hirers please note that Camp facilities, such as bungalows, recreational facilities, canteen, etc., are located on different spots of a slope and connected by pavements.

 

This arrangement is similar to what we’ve seen elsewhere, including Singapore (see MERS: Singapore MOH Puts Quarantine Chalets On Standby).  Earlier this year, in EID Journal: A Brief History Of Quarantine, I wrote about the use of quarantine and isolation with the 2003 SARS outbreak:

 

During the 2003 SARS epidemic, Isolation was used in the United States for patients who were ill, but since transmission of the virus was very limited here, quarantine was not recommended for those exposed (cite).

In other countries, where transmission risks were greater, quarantines were used – quite successfully – in order to contain the virus.

• Singapore was one of the first countries to mandate quarantines when more than 800 family members of SARS patients were ordered to stay in their homes. 
• Hong Kong sealed part of the Amoy Gardens Apartment complex after scores of cases erupted there, and later moved all remaining residents to two holiday camps where they were quarantined.
• And Toronto, Canada closed schools and quarantined thousands in their bid to contain the virus (see The SARS Experience In Ontario, Canada).

 

While we don’t know how many mild or asymptomatic cases of H7N9 may have occurred, so far the number of severe cases detected by Chinese public health authorities suggests the virus hasn’t yet gained the ability to spread easily and efficiently among humans.

 

We have seen evidence of a few small clusters, and research over the summer suggests that the virus may not have that far to evolve to pose a pandemic threat (see Nature: Receptor Binding Of H7N9).

 

So public health interventions – such as quarantining those with likely exposure until infection can be ruled out – is a prudent and necessary step.

HK CHP: Notification Letter To Doctors On H7N9 Case

 

 

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One of the reason’s Hong Kong’s CHP is so well regarded among bloggers is they proactively release information to the public that other public health agencies might try hide, or at least gloss over.  Such was the case yesterday with the rapid confirmation of Hong Kong’s first (likely, imported) case of H7N9 (see Video: HK Officials Seeking Traveling Companion Of H7N9 Patient).

 

Today, HK’s CHP openly published a letter to local doctors and hospitals with additional details on this case, which provides us with the most detailed timeline of this patient’s illness and diagnosis to date.

 

Our Ref. :   (102) in DH SEB CD/8/6/1 Pt.27                                                 3 December, 2013

Dear Doctors,

A Confirmed case of Human Infection with Avian Influenza A(H7N9) virus and Activation of Serious Response Level of Government’s Preparedness Plan I would like to draw your attention to a confirmed case  of human infection with avian influenza A(H7N9) virus in Hong Kong. The patient  is a 36-year-old Indonesian maid. She lives with her employer's family (six family members)  in Tuen Mun in Hong Kong.

 

She had onset of cough on 21 November 2013 and developed fever on 22 November. She sought medical attention from two general practitioners on 25 and 26 November.  She developed shortness of breath on 27  November and attended Accident and Emergency Department of Tuen Mun hospital (TMH) and chest X-ray on admission showed right lower lobe consolidation.  She was admitted to TMH and was transferred to intensive care unit for treatment on 29 November.  Her condition deteriorated and she was transferred to Queen Mary Hospital for extracorporeal membrane oxygenation on 30 November by ambulance.

 

Her nasopharyngeal swabs and aspirates were tested positive by polymerase chain reaction (PCR) for influenza A and H7 and N9 on 2 December, confirming the diagnosis of influenza A (H7N9) by Public Health Laboratory Services Branch (PHLSB) of the Centre for Health Protection (CHP).  Her current condition is critical.

 

Preliminary epidemiological investigation revealed that the patient went to Shenzhen of Guangdong Province on 17 November for a day trip. She bought a live chicken in a market and ate after cooking  with a friend in Shenzhen. CHP of the Department of Health (DH) is communicating with the Guangdong Health Department to investigate the source of her infection. According to available information, this is likely to be an imported infection. CHP is tracing the exposed close contacts of the patients and will provide them with chemoprophylaxis and put them under quarantine. So far, four of the close contact had symptoms including cough, runny nose or sore throat and have been isolated in hospital. Investigation is on-going.

The Government has raised the influenza response level from “Alert” Response Level to “Serious” Response Level under the Framework of Government’s Preparedness Plan for Influenza Pandemic. Prior to this case, no human infections with avian influenza A(H7N9) virus were recorded in Hong Kong. According to the latest update from the National Health and Family Planning Commission of the People's Republic of China (28 November 2013), a total of 140 cases of human infection with  avian influenza A(H7N9) virus have been reported.

In response to the newly confirmed imported case in Hong Kong, we have enhanced surveillance by activating zero reporting with both public and private hospitals. We would like to urge you to pay special attention to those who presented with influenza-like illnesses and had history of visiting wet market with live poultry or contact with poultry in Guangdong Province and other affected areas within the incubation period (i.e. 10 days before onset of symptoms). Please kindly be  reminded that the list of affected areas is regularly updated and is available at the CHP website:

(http://www.chp.gov.hk/files/pdf/global_statistics_avian_influenza_e.pdf). 

Any suspected case meeting the reporting criteria (https://ceno.chp.gov.hk/casedef/casedef.pdf) should be immediately reported to the Central Notification Office of CHP via  fax (2477 2770), phone (2477 2772) or CENO On-line (www.chp.gov.hk/ceno). Please also contact the Medical Control Officer (MCO) of DH at Pager: 7116 3300 call 9179 when reporting any suspected case. DH will make arrangement to send the patient to regional  public hospitals for isolation, testing and treatment. Please isolate patient to minimize contact/exposure to staff and other patients and advise the patient to wear a surgical mask while waiting for transport.

 

For updates on the latest situation of avian  influenza, please visit CHP website at http://www.chp.gov.hk/en/view_content/24244.html. Thank you for your ongoing support in combating communicable diseases.

Yours sincerely,
(Dr. SK CHUANG)
for Controller, Centre for Health Protection
Department of Health

UAE: Media Reporting Death Of Mother In Family MERS Cluster

Credit WIkipedia

 

# 8033

 

 

While much of our attention today has been focused on Hong Kong’s first imported H7N9 case, another story we’ve been following has been the family cluster of MERS in Abu Dhabi, consisting of a 38 year old husband, his 32  year-old wife, and 8 year old son (see WHO MERS-CoV Update – Dec 2nd).  The mother was 8 months pregnant, in critical condition,  and reportedly delivered in the past 24 hours.

This afternoon, multiple news sources are reporting she has died .  This from  The National.

 

Mother of Jordanian boy, 8, diagnosed with Mers coronavirus dies in Abu Dhabi

The National staff

December 2, 2013 Updated: December 2, 2013 23:01:00

The mother of an eight-year-old Jordanian boy diagnosed with the Mers coronavirus (Mers-Cov) in Abu Dhabi has died, the Health Authority-Abu Dhabi (Haad) announced on Monday.

 

The woman, 32, had been in critical condition and had recently given birth after being hospitalised because of the illness, the World Health Organisation said.

 

The boy and his father, 38, are stable and they are receiving the required care, Haad said.

 

Local news agency Wam reported that the boy was found to have Mers-Cov during medical check-ups of family members after his father was recently diagnosed with the same virus.

(Continue . . . )