Yesterday, the World Health Organization (Disease Outbreak News, January 17, 2017) provided information on a recent H7N9 case from Hong Kong and enumerated an additional 106 cases from China reported through January 9, 2017. According to WHO, the 106 cases were reported from 7 provinces. The WHO states that through January 9 the total number of reported H7N9 cases since 2013 is 916.
However, according to lists published by the Hong Kong Centre for Health Portecton (CHP), perhaps as many as 116 cases have been reported from China between December 2016 and January 9, 2017. The CHP has provided some cases detail individually for almost all of these cases, including gender, age, and status at the time of report. Comparing the WHO tabulation with the CHP data, it is clear that cases reported in some provinces were not included in the WHO tabulation. Three provinces reported eight cases that are not included in the WHO report, six cases are from Jiangsu, one cases from Shandong, and one case from Guizhou. Since these cases were reported as confirmed by the FAO during this period it is not clear why the WHO failed to include these additional cases in the totals.
Another example of confusion is the number of reported cases from Anhui Province. The WHO noted a total of 14 cases from Anhui Province. This number was originally published by the Anhui Provincial Health and Family Planning Commission as noted in this FluTrackers post. In the Week 52 Avian Influenza Report from the CHP published on December 28, 2016, seven new cases of H7N9 were reported from Mainland China health authorities, five of the cases were from Anhui Province, but no case details were provided. In the Week 1 Avian Influenza Report the CHP reported an additional nine cases reported from Anhui Province with case details for each of the individuals. These two CHP reports indicate that the count of cases from Anhui Province for December 2016 is 14.
Yet, the tracking of public announcements and news media reports from the Anhui Province by FluTrackers members only identified 10 individual cases (FT list), not 14. As an independent check on the number of cases from Anhui Province, I consulted the database of human H7N9 cases maintained by the Food and Agricultural Organization of the United Nations (FAO) on January 10, 2017. On the 10th of January, the FAO listed a total of 16 confirmed human H7N9 cases from Anhui Province.
The table below lists each of these cases by the Disease Event Number, and the City and Region, and the reporting date. Sixteen confirmed cases is two more than the 14 reported. I rechecked the FAO database yesterday, five of the confirmed cases had been removed from the database. Those cases are highlighted in yellow in the table. It is unclear what happened, but it is likely those five deleted cases were human samples were that were duplicated, resubmitted, and double counted as additional cases in the province. The final listing of 11 FAO cases in Anhui Province corresponds better with the individual case count tabulated by FluTrackers members.
Discussion
I have just spent some time discussing the minutia of counting and enumerating H7N9 cases. Was the effort worth it? Is there any reason we should care about these minor discrepancies in the counting of human cases of H7N9 between various public health agencies? After all, these case discrepancies will be cleared up over time, at least among the databases maintained by the health agencies, even if the corrected information is not made available to the public.
The fact is we should be extremely concerned about the public reporting process of infectious diseases. Extrapolating from the presumed onset dates along with the number of reported fatalities at the time of reporting, China did not meet the goal of reporting H7N9 cases within a 24 hour period as specified by International Health Regulations. Since the first reported cases of H7N9 in 2013, China has had several years to develop a smooth reporting strategy for H7N9 cases. By now, national and international public health agencies should have their own process of accurately tracking and computing cases of an infectious disease such as H7N9.
With more than 100 new cases of H7N9 reported from China in a little over 30 days, the tracking and reporting process seems to be strained and overwhelmed already. What will happen in the event there is human to human transmission and instead of three or four cases a day, tens or hundreds might be reported. We do not want our public health agencies to fail in their mission of keeping the public informed and quickly up-dating information as the infections spreads.
However, according to lists published by the Hong Kong Centre for Health Portecton (CHP), perhaps as many as 116 cases have been reported from China between December 2016 and January 9, 2017. The CHP has provided some cases detail individually for almost all of these cases, including gender, age, and status at the time of report. Comparing the WHO tabulation with the CHP data, it is clear that cases reported in some provinces were not included in the WHO tabulation. Three provinces reported eight cases that are not included in the WHO report, six cases are from Jiangsu, one cases from Shandong, and one case from Guizhou. Since these cases were reported as confirmed by the FAO during this period it is not clear why the WHO failed to include these additional cases in the totals.
Another example of confusion is the number of reported cases from Anhui Province. The WHO noted a total of 14 cases from Anhui Province. This number was originally published by the Anhui Provincial Health and Family Planning Commission as noted in this FluTrackers post. In the Week 52 Avian Influenza Report from the CHP published on December 28, 2016, seven new cases of H7N9 were reported from Mainland China health authorities, five of the cases were from Anhui Province, but no case details were provided. In the Week 1 Avian Influenza Report the CHP reported an additional nine cases reported from Anhui Province with case details for each of the individuals. These two CHP reports indicate that the count of cases from Anhui Province for December 2016 is 14.
Yet, the tracking of public announcements and news media reports from the Anhui Province by FluTrackers members only identified 10 individual cases (FT list), not 14. As an independent check on the number of cases from Anhui Province, I consulted the database of human H7N9 cases maintained by the Food and Agricultural Organization of the United Nations (FAO) on January 10, 2017. On the 10th of January, the FAO listed a total of 16 confirmed human H7N9 cases from Anhui Province.
The table below lists each of these cases by the Disease Event Number, and the City and Region, and the reporting date. Sixteen confirmed cases is two more than the 14 reported. I rechecked the FAO database yesterday, five of the confirmed cases had been removed from the database. Those cases are highlighted in yellow in the table. It is unclear what happened, but it is likely those five deleted cases were human samples were that were duplicated, resubmitted, and double counted as additional cases in the province. The final listing of 11 FAO cases in Anhui Province corresponds better with the individual case count tabulated by FluTrackers members.
Discussion
I have just spent some time discussing the minutia of counting and enumerating H7N9 cases. Was the effort worth it? Is there any reason we should care about these minor discrepancies in the counting of human cases of H7N9 between various public health agencies? After all, these case discrepancies will be cleared up over time, at least among the databases maintained by the health agencies, even if the corrected information is not made available to the public.
The fact is we should be extremely concerned about the public reporting process of infectious diseases. Extrapolating from the presumed onset dates along with the number of reported fatalities at the time of reporting, China did not meet the goal of reporting H7N9 cases within a 24 hour period as specified by International Health Regulations. Since the first reported cases of H7N9 in 2013, China has had several years to develop a smooth reporting strategy for H7N9 cases. By now, national and international public health agencies should have their own process of accurately tracking and computing cases of an infectious disease such as H7N9.
With more than 100 new cases of H7N9 reported from China in a little over 30 days, the tracking and reporting process seems to be strained and overwhelmed already. What will happen in the event there is human to human transmission and instead of three or four cases a day, tens or hundreds might be reported. We do not want our public health agencies to fail in their mission of keeping the public informed and quickly up-dating information as the infections spreads.
Comment