NEJM: Probable Hospital Cluster of H7N9 Influenza Infection

[Gert van der Hoek]

China - NEJM: Patient-to-Doctor Spread of H7N9 Bird Flu Reported

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[TD="bgcolor: #E8E8FF"]But odds are slim that deadly virus will spread easily among people, experts say[/TD]
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WEDNESDAY, Feb. 10, 2016 (HealthDay News) --

Deadly H7N9 bird flu can, in certain situations, be transmitted person-to-person in hospitals, according to a new report from China.

Since bird flu first appeared in eastern China in 2013, nearly 700 people have been infected, the study authors said. Almost 300 people have died as of Jan. 10, 2016. Most of the infections and deaths have occurred in China, the authors said.

People usually get this flu from infected birds, but clusters of infections in households have been reported. This is the first report, however, of person-to-person transmission occurring in a hospital, the researchers said.

"Our study shows a patient with H7N9 bird flu in a hospital in Shantou, China infected two doctors," said lead researcher David Kelvin, from the International Institute of Infection and Immunity in Shantou.

"This is alarming because it shows that human-to-human transmission is possible in a hospital setting," he said. "Normally, H7N9 bird flu is spread from chickens [or poultry] to humans, and 30 percent of human cases die of severe pneumonia."
The report was published in the Feb. 11 issue of the New England Journal of Medicine.

According to the report, the patient, a 28-year-old man with repeated exposure to live poultry, was admitted to the hospital suffering from what turned out to be H7N9 flu. During his stay, two doctors he had close contact with also came down with the illness.

These cases occurred from January to February 2015. Fortunately, all three patients recovered and were discharged from the hospital, researchers said.

"Most hospital staff do not think they can get H7N9 bird flu from people," Kelvin said.

He added that the lesson from this incident is that hospital staff must take all necessary precautions when treating H7N9 bird flu patients, including wearing gloves, masks and gowns, and isolating patients.

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[Gert van der Hoek]

Probable Hospital Cluster of H7N9 Influenza Infection

N Engl J Med 2016; 374:596-598February 11, 2016DOI: 10.1056/NEJMc1505359

To the Editor:

Avian influenza A (H7N9) virus emerged in eastern China in the spring of 2013,1 with 698 cases and 281 deaths reported as of January 10, 2016.2 Human H7N9 infections appear to be acquired through zoonotic transmission, although clusters of human-to-human household transmission have occurred.3,4 We report here a hospital cluster of H7N9 infections that took place from January to February 2015. This study was approved by the ethics committee at Shantou University Medical College.

A 28-year-old man (index patient), with repeated exposure to live poultry, presented with respiratory infection and was admitted to the respiratory department, where his condition worsened. Laboratory investigation of serum and sputum samples obtained later in the course of illness showed that he was positive for H7N9 by serologic testing and polymerase-chain-reaction (PCR) assay. Seven days after admission of the index patient, influenza-like illness developed in a 33-year-old male physician (Doctor 1) who attended the index patient. The acute respiratory distress syndrome later developed in this physician. Four days after the onset of symptoms in Doctor 1, influenza-like illness and bronchial pneumonia developed in a second attending physician (Doctor 2), a 35-year-old man, in the same department .

Clinical Events and Phylogenetic Analysis of the H7N9 Influenza Cluster.). He too had close contact with the index patient. Although standard infection-control practices, including the wearing of personal protective equipment, are hospital policy when caring for patients with H7N9 infection, the use of these practices by the attending physicians while caring for the index patient could not be verified. No other common epidemiologic link among these three persons was identified, and all are unrelated.
With the use of real-time reverse-transcriptase–PCR assay, seroconversion (hemagglutination-inhibition assay and microneutralization antibody assay), and viral isolation (methods detailed in the Supplementary Appendix, available with the full text of this letter at NEJM.org), H7N9 infection was confirmed in all three persons; they recovered from their illness and were discharged from the hospital (Figure 1A, and Fig. S1, Table S1, Table S2, and case reports in the Supplementary Appendix). Even though the index patient appeared to be convalescent at the time of discharge, he continued to shed H7N9 virus 42 days after the initial onset of symptoms.

Sequence and phylogenetic analyses of viral isolates from the index patient, Doctor 1, Doctor 2, and eight additional, unrelated patients with H7N9 infection who were hospitalized during the 2015 outbreak (Figure 1B, and Table S4 in the Supplementary Appendix) showed that all 11 isolates are genetically closely related; however, the 3 hospital isolates form an independent clade with a bootstrap support of 86% (Figure 1B) and carry two unique nucleotide polymorphisms (HA-A865T and HA-C1275T). We also observed that H7N9 viruses currently isolated in Shantou emerged from a small reassortant group5 that carries distinct segments of PB2 and MP (Figure 1C, and Fig. S2 and Table S5 in the Supplementary Appendix). The three viruses isolated from the index patient, Doctor 1, and Doctor 2 suggest direct human-to-human transmission; although a common community source cannot be ruled out, no such sources were identified. Management of the care of patients with suspected H7N9 infection should include proper infection-control practices.

 

[tetano]

Avian influenza A (H7N9) virus emerged in eastern China in the spring of 2013,1 with 698 cases and 281 deaths reported as of January 10, 2016.2 Human H7N9 infections appear to be acquired through zoonotic transmission, although clusters of human-to-human household transmission have occurred.3,4 We report here a hospital cluster of H7N9 infections that took place from January to February 2015. This study was approved by the ethics committee at Shantou University Medical College.

A 28-year-old man (index patient), with repeated exposure to live poultry, presented with respiratory infection and was admitted to the respiratory department, where his condition worsened. Laboratory investigation of serum and sputum samples obtained later in the course of illness showed that he was positive for H7N9 by serologic testing and polymerase-chain-reaction (PCR) assay. Seven days after admission of the index patient, influenza-like illness developed in a 33-year-old male physician (Doctor 1) who attended the index patient. The acute respiratory distress syndrome later developed in this physician. Four days after the onset of symptoms in Doctor 1, influenza-like illness and bronchial pneumonia developed in a second attending physician (Doctor 2), a 35-year-old man, in the same department (Figure 1AFigure 1Clinical Events and Phylogenetic Analysis of the H7N9 Influenza Cluster.). He too had close contact with the index patient. Although standard infection-control practices, including the wearing of personal protective equipment, are hospital policy when caring for patients with H7N9 infection, the use of these practices by the attending physicians while caring for the index patient could not be verified. No other common epidemiologic link among these three persons was identified, and all are unrelated.

http://www.nejm.org/doi/full/10.1056/NEJMc1505359

 

[sharon sanders]

We have this cluster of cases listed for January - February 2015 in Shantou. There is no previous report of a case that fits the city, age, or time period of the 2nd doctor mentioned above:


#522 - Male, 68, [Houmou], hospitalized, Shantou, Guangdong province (CHP announced this case. It is possible there is a typo at CHP/NHFPC and the real age is 28.)

#584 - Male, 33, [Moumou] diagnosed February 9, in critical condition, Shantou, Guangdong province (This case is apparently one of the doctors mentioned above)

#588 - Male, 60, [Daimou], diagnosed February 11, hospitalized in critical condition, Shantou, Guangdong province

#600 - Female, 48, [Hwang], hospitalized in critical condition, Shantou, Guangdong province (CHP announced February 27)

#601 - Male, 51, [Shimou], hospitalized in critical condition, Jinping, Shantou, Guangdong province (Diagnosed February 20)

#616 - Male, 80, [Wu], hospitalized in critical condition, Chaoyang district, Shantou city, Guangdong province (Reported February 26)


It appears, not coincidentally, the Chinese mainland government transitioned during this time period to reports that give general outbreak information by province with no detail regarding cases:

WHO DON January 19 containing information about December 2014 cases - case details are included link

WHO DON February 8 containing information from 20 December 2014 to 27 January 2015.without any case details link

WHO DON March 9 containing information from 21 January to 25 February 2015.without any case details link

WHO DON April 15 containing information from 14 February to 21 March 2015 without any case details link

 

[sharon sanders]

I am going to add the 2nd doctor to our case list. Also, I would like to point out that including the 2nd doctor there were 7 H7N9 cases reported in Shantou in the same time frame.