Cooperation between usual foes regarding bird flu is certainly not new:  The Israelis and the Palestinian Authority have regular conference calls on spotting and eradicating H5N1. Good to see these two nations talking.  Maybe there's hope for the Koreas.  Nope, I just jinxed it.

Next comes the actual detail on the Taiwan case, courtesy of Mike Coston's blog.  Seems the individual A) just returned from Jiangsu province earlier in April, and B) presented symptoms shortly afterward.  he was hospitalized on April 16th.  After two straight negative tests for H7N9, he finally tested positive.

"If at first you don't succeed, stop" seems to be the norm for avian influenza testing.  In this case, the Taiwanese tested again (good for them), and successfully achieved a positive test.  From the Taiwan CDC report:

指揮中心經與中國大陸疾病預防控制中心查證確認，扣除昨(4/23)日已發布之山東省首發...

Just kidding.  From the Taiwan CDC report, which I have reformatted for emphasis on the dateline:

During March 28 and April 9, 2013, the patient traveled to Suzhou. 

On April 9, he returned to Taiwan from Shanghai.  According to the case, he had not been exposed to birds and poultry during his stay in Suzhou and had not consumed undercooked poultry or eggs. 

On April 12, he developed fever, sweating, and fatigue, but no respiratory or gastrointestinal symptoms. 

On April 16, he sought medical attention at a clinic when he developed high fever and was transferred to a hospital by the physician. He was then hospitalized in a single-patient room for further treatment.

On April 16, he was administered Tamiflu. 

On April 18, his chest x-ray showed interstitial infiltrate in the right lower lung.  On the night of April 19, his conditions worsened. 

On April 20, he was transferred to a medical center for further treatment. He was then intubated due to respiratory failure and placed in the negative-pressure isolation room in the intensive care unit. During his stay in the hospitals, two throat swab specimens were collected and both tested negative for avian influenza A (H7N9) virus by real-time RT-PCR. 

On April 22, the medical center collected a sputum specimen from the patient and the specimen was tested positive for influenza A. 

In the morning of April 24, avian influenza A (H7N9) virus was detected in the sputum specimen using real-time RT-PCR. 

In the later afternoon of April 24, the National Influenza Center in Taiwan confirmed the identification and completed the genome sequencing of the virus. 

OK, let's review.  Independent analysis from several Australian experts is showing an average nine-day period between exposure and the presentation of severe symptoms.  Based on this, I would speculate that he acquired the virus around April 6th or 7th.  Check.  It would be nice to know where he was on those days.  The narrative also shows that, for a period of four days (!), he was in a normal, single-patient hospital room, his condition gradually worsening.  On April 22nd (!), he was intubated and placed in a negative air-pressure room.

This tells me that the Taiwanese had no Earthly idea they had an H7N9 patient in their midst, even though he was being treated for flu, was geting worse, and had just come from a relative hotbed of H7N9.

What is very troubling, disconcerting, wringing-the-hands worrisome is that three attending health care workers are now feeling sick, and they have -- wait for it -- flu-like symptoms. Back to Crof for that report.

From the same Chinese CDC release:

Of the 110 healthcare workers (who attended the patient), 4 have passed the 7-day incubation period and shown no symptoms.  Only three contacts failed to put on appropriate personal protective equipment when the contact occurred.  Thus far, the three have not developed symptoms, but they will be followed up until April 27, 2013. On the other hand, while delivering healthcare services, three healthcare workers who were geared with appropriate personal protective equipment developed symptoms of upper respiratory infection.  The public health authority have conducted thorough health education activities for all contacts, issued them with “Self-Health Management Advice for H7N9 Influenza”, and will be following up with them closely until the period of voluntary contact tracing is lifted.  When a contact develops influenza-like illness symptoms such as fever and cough, the public health authority will voluntarily assist the individual in seeking medical attention.

I wonder how these apparently-sick healthcare workers sync with the "single room" timeline.  It was two days prior -- on April 18th -- that the US CDC issued guidance, including the placement of suspected H7N9 to be put into negative air-pressure rooms, even absent a positive test result.

Where I am going is that, even in Taiwan, so close to mainland China they can almost feel it, it took three tests to confirm H7N9, and they kept a really sick guy in a general room for four days - two days beyond the US CDC guidelines were published on the Nets.

Now the other revelation concerning this Taiwanese man is his concurrent battle with Hepatitis B.  I am the furthest thing from expert on Hepatitis, so I defer to Crof's blog of a few days ago, regarding co-infection.  It seems many of the same people who have contracted H7N9 are also suffering/living with Hepatitis B.

But yesterday, such a derailment happened.  And in so doing, it became a metaphor for both China's dilemma in dealing with the H7N9 outbreak, as well as dealing with the emerging attitudes of its people.

A person who I know and brought in to speak at an IT conference a few years ago is Thomas P.M. Barnett.  Barnett is the author of The Pentagon's New Map, which is a great book about how the United States must change how it goes about nation-building.  As if we have had any lasting success at doing that since World War II.  Anyway, Thomas has traveled to China, and told me they are engaged in "rampant Capitalism." He also predicted that in twenty years, China would no longer be a Communist nation. He said this back in 2006.

When one looks at the Chinese government's emerging attitudes regarding transparency, first during SARS and now during H7N9, I see the emerging signs of which Mr. Barnett spoke. Another is the emergence of Chinese Twitter-wanna-be site Weibo, and how that site is rapidly changing Chinese citizens' ability to share information.  Simply put, the combination of Capitalism, Direct Foreign Investment, along with the Internet and Chinese homegrown social media, are all conspiring to radically alter the political landscape of China. 

So it is in this light that I read of the derailment of an official Shanghai H7N9 press conference by the 26-year-old daughter of two bird flu victims.  Her simple questions have also focused attention on the second suspected cluster of human-to-human transmission of H7N9 since the outbreak began in late February.

The article was posted in the Chinese newspaper The South China Morning Post.

Officials were going about their statements when a question was taken from the floor.  The 26-year-old daughter of the second suspected family cluster of H7N9 asked why local public health officials were not being more transparent with her about her father's condition.  Her mother had already perished from confirmed H7N9, and her father was still in a special unit, being administered to.

Some snippets from the newspaper article:

"The hospitals and medical staff appear friendly to members of the media like you but have responded in a lukewarm manner to inquiries from family members like me," the 26-year-old, who would only identify herself as Gu, told the South China Morning Post. "I wanted to ask the senior officials about my father's condition and thought the press conference would provide a good opportunity."

She was picked by city government spokesman Xu Wei to ask a question, but was interrupted by him after she identified herself as the daughter of patients in another confirmed family cluster of H7N9 cases in Shanghai.

She had hoped to question Wu Fan, director of the Shanghai Centre for Disease Control and Prevention, but was not allowed to speak.

"I am awfully worried because my father was said to be in critical condition," she said. "I hoped to ask director Wu what family members could do to help in the treatment."

Her mother died of the new strain of bird flu on April 3, and her father was confirmed to have been infected by the same virus on April 13. The daughter, who is studying abroad, has not seen her father since she returned to Shanghai on April 4.

He is now in quarantine and being treated at the Shanghai Public Health Clinical Centre in the city's suburban Jinshan district.

The woman was taken away by officials after she spoke to reporters following the press conference.

She said Wu had promised to give her a reply after checking with the medical staff in charge of her father's treatment.

State leaders including President Xi Jinping have pledged to enhance transparency in the release of information about the H7N9 outbreak.

In Shanghai, the city government has been praised by the media for promptly releasing of H7N9-related information, but several family members of patients have complained that hospitals and doctors have tried to cover up cases. (bold mine)

I feel sorry for city government spokesman Xu Wei.  He is probably the spokesman for some Chinese re-education camp today. I doubt he had time to pack. And I hope the daughter is being treated fairly.

Bottom line:  There's detectable frustration in Shanghai regarding how patients are faring. Shanghai residents also feel that there is some serious covering-up going on, and in truth, there may be.  Clearly, the foreign press is getting the information, but the family members of the dead and sick feel they are not.

Please check this site out.  It will help you draw conclusions that you simply cannot visualize when reading the static data.

Of particluar help is his chart showing the individual cases against the backdrop of such things as the culling of poultry in the major sities reporting H7N9 cases.  If the birds were, indeed, the culprit, then we should see a decline in the number of human cases. 

Dr. Mackay's summation:

Some things we don't know...

How may are infected without obvious signs of infection

[With thanks to Dr. Katherine Arden for contributing to the questions and thoughts below]

 

• The source of the human infection
• Whether human-to-human transmission is occurring
• The scope of H7N9 genetic change in real-time (too few sequences to date)
• The nature, specificity and effectiveness of H7N9 assays
• The seroprevalence of H7N9 in humans
• The range of signs and symptoms attributable to H7N9
• How may are infected without obvious signs of infection

 

“This is one of the puzzles still [to] be solved and therefore argues for a wide investigation net,” Hartl said. “It might be because of dust at the wet markets, it could be another animal source beside poultry, it could also be human-to-human transmission,” he said.

The idea of "dust" is not a far-fetched one, but it does warrant some explanation.  We know that viruses are also subject to the laws of gravity.  Virus particles will, inevitably, drop to the ground -- only to be kicked back up again when disturbed.  I alluded to this in an older post, from 2007.

During the SARS almost-pandemic, vacuuming of hotel carpets in China contributed to the spread of the disease.  The cruise ship industry's protocol when confronted with an outbreak of norovirus on a ship at sea includes the cessation of vacuuming.  And my lectures and presentations on pandemic preparations include this same advice.

It is entirely possible that "dust" from the floors of wet markets might have contributed to the incidence of human cases, but it still would not point us toward the source of the infections. Something/someone had to deposit that "dust" on the floor of the market. Clearly, the WHO feels that poultry remains the most likely candidate.  However, continued testing of poultry from wet markets in Shanghai and elsewhere have failed to find the "smoking chicken" everyone desperately needs to find, before this virus goes through enough mutations for find -- voila! -- a branch of this flu with the ability to move at will amongst humans.

And if the culprit is not poultry, then is there another vector depositing virus on the floors of, say, bus depots, other markets, hotels, restaurants, or newsstands?

"Worsened" could be worse.  First, the Monday morning reset:  We have 106 confirmed human cases of H7N9 avian influenza.  We have a suspected confirmed human case in yet another province, Shandong.  And we still have no Earthly idea what (or who) the vector of transmission is.

But we still do not have the exponential growth (think of that old shampoo commercial) in cases that would signal the beginning of sustained human-to-human transmission of H7N9. 

Just one week ago, we had 72 human cases.  Friday, we had 91 cases.  And as I mentioned, today we have 106 cases.  Now the attention turns to what we don't know; namely, guessing how many unreported or undiagnosed cases there might be.

In the absence of previous testing, we are simply guessing.  As Spock said in Star Trek IV, they are making the best guess they can possibly make. From sleepless blogger Mike Coston's morning joe entry:

If, as these scientists suggest, there are really 200 cases out there, then the case fatality rate (now sitting at 20%) would be cut to (a still impressive) 10%.

We don't know when the infection started.  We don't know the carrier. We suspect wild birds have communicated the disease to poultry, but the number of positives found while testing eastern Chinese poultry probably is not that much greater than what you might find in the Netherlands or Germany.

And, believe me, they are testing poultry in Europe!  Flutrackers.com reports that H7 has been found in a turkey farm in Saxony.  27,000 birds are meeting their Maker. While low-path, as is the Chinese outbreak (if only in poultry), the Germans know the entire flock must be wiped out.

Back to China.  The virus has spread to yet another province, and Zhangzou has overtaken Shanghai as the province with the highest number of reported cases.

Veteran flu tracker laidback AL, he of the superb charts, brings us yet another gem.  The gem is flawed; it was created before Shandong came on the map. But it does show the new leader in confirmed cases, Zhegiang.

The mapo also shows the proximity of Shandong Province to the other eastern provinces.  From Wikipedia:

Shandong has emerged as one of the most populous (95,793,065 inhabitants at the 2010 Census) and most affluent provinces in the People's Republic of China (GDP of 3.94 trillion CNY in 2010).

Add another 95 million people to the mix of potential mixing vessels.

Some takeaways from the 2PM EDT conference call:

Persons exhibiting influenza-like illness and/or severe respiratory distress, and who have either traveled to China or have had close contact with someone who has traveled to China, need to be considered in a separate category and closely monitored.

Any Influenza-Like Illness within this subset that cannot be conclusively diagnosed as seasonal influenza needs to be considered suspected H7N9, and samples are to be sent to the CDC immediately.

Suspected patients should be put into isolation, preferably in an appropriate environment, negative-air-pressure room (AIIR).

It is unknown whether rapid office tests could detect avian influenza.  Therefore, all commercially available influenza tests should be disregarded when testing for H7N9. It should be assumed they are inaccurate.

The CDC is currently the only testing facility in the United States that can test reliably for H7N9.  This will change as the CDC certifies states with the ability to detect H7N9.

The CDC is advising organizations to review and revise their pandemic plans.

International airports with frequent travel to and from China have begun listing H7N9 information on their electronic signs, particularly in Customs areas.

Limited human-to-human transmission has occurred in China. Which is a) not surprising and b) probably expected.

Put people on Tamiflu immediately upon suspicion of H7N9, even if they have presented symptoms for more than 48-hours.

CDC can have test results within hours of receipt of the samples.

Clinicians need to collect specimens and notify their state health department for instructions.

There have been cases, as recently as March, where people tried to illegally smuggle Chinese poultry into the United States. 

(Of course, this was a concern back in 2007.  Recalal than in July, 2006, a Troy, Michigan warehouse was raided for suspicion of illegally-imported goose parts.  The boxes were later stolen from the Government-sealed warehouse.  )

This is getting real interesting real fast.

International health officials are scratching their heads over the paucity of positive bird tests for a bird flu, especially given that the human case count is more than double the number of positive bird findings. As of Wednesday, 82 people had been infected and 17 had died.

"Something is happening out there that's not being picked up," says Gregory Hartl, spokesperson for the World Health Organization in Geneva.

"It argues for the fact that we have to continue to cast the investigation net widely."

Xinghua, the official Chinese news service, reported just today:

BEIJING, April 17 (Xinhua) -- Animal infections of the H7N9 avian flu have only been detected in live poultry markets and a single wild pigeon, agricultural authorities said Wednesday.

Of the 47,801 samples collected from more than 1,000 poultry markets, habitats, farms and slaughterhouses across the country, 39 samples have tested positive for the virus, the Ministry of Agriculture said in a statement.

Of the 39 positive samples, 38 came from live poultry markets in east China's Jiangsu and Zhejiang provinces, central China's Anhui Province and the city of Shanghai.

A wild pigeon tested positive for the virus in Jiangsu.

The virus has not been detected in pigs, the ministry said.

But in the end I came away convinced that Hong Kong is taking this very seriously. They have to. They've seen what a new infectious disease can do.

Wherever the virus is, it ain't showing up in chickens.

Or is it? Branswell further writes:

Those findings beg the questions: Where is this bird flu hiding? And is China targeting the right species when it goes looking for H7N9?

Infectious diseases expert Michael Osterholm agrees with the suggestion that at this point, investigators need to keep an open mind about where the virus may be coming from.

But the director of the Center for Infectious Diseases Research and Policy at the University of Minnesota says too little is known about how China is testing for anyone to be confident that all the negative bird tests were true negatives. He suggests more information is needed before people can feel sure that the results being reported are truly as puzzling as they seem.

"There are just a number questions here that we can't answer yet based on the available information," Osterholm said in an interview.

"I think the Chinese have been very forthcoming in providing the results. I think the question now is how to interpret these results… based on how they got the results."

Osterholm says the questions that need to be answered are: What types of tests are being performed on samples taken from animals and how well are those tests doing at detecting the new virus?

To put this in context, one needs to understand that there was no on-the-shelf test for this H7N9 virus, which is a constellation of bird flu genes that hadn't been seen before.

Veteran readers of this blog know of my friendship with, and immense respect for, Dr. Mike Osterholm.  I think he is on to something here. We have a novel virus that we were totally unprepared for.  We have little capability for testing for the presence of the disease.  The testing reagents are literally just off the truck.  And the Chinese are ramping up a lot of spare labor to go out into the differne regions of the country to test.

I do not know just how difficult it is to swab a chicken's anus, and I am thinking there must be a hidden joke in there somewhere.  Anyway, I am thinking of the old Dean Martin Roasts on TV.  Once, Lucille Ball said, "Dean, you rub me the wrong way."  Martin quipped:  "I didn't know there was a wrong way!"

But I, as usual, digress. I had no idea there was a wrong way to swab a chicken's cloaca.

Mike Osterholm is saying that we are mising something.  So is Hartl.  What is it that we are missing?  Pigs are negative.  Chickens are negative.  

Crof had a great blog entry this morning.  In it, he posts the Good Morning, America report of Dr. Richard Besser.  Dr. Besser, as you may recall, ran the CDC during Wave One of the Swine Flu/pH1N1 Pandemic. Here's part of what he said, observing first-hand the "testing" of live poultry as it was being imported into Hong Kong:

Then the first truck of chickens pulled in to be screened. A team of around 15 agricultural workers wearing white coats, rubber boots, surgical gloves and face shields descended on the truck. One worker cut off the seal that had been placed on the door to the truck at the poultry farm in Guangdong Province. Then with the speed and precision of an army drill team, they went to work.

 

They selected 30 chickens at random from the thousand or so in the truck. Each bird had the same fate: a sample of blood was drawn; a cloacal swab was obtained; and the bird was returned to its cage. The whole operation from the time the truck pulled in to when it departed with a fresh seal took no more than 30 minutes. By law, the seal cannot be removed until at least five hours later, when the rapid testing for H7N9 is completed.

But I still have a few unanswered questions: How good is the rapid test for H7N9? And is testing 30 chickens enough? Perhaps you need to test more to be certain that the flock is clean.

 

As of noon today, we stand at 88 confirmed cases and 17 deaths.

This article sums it up nicely. Apparently the hot Chinese social media site is Weibo.  the Chinese are learning that the Internet, and accompanying social media, are forcing transparency. Good.

And Declan Butler is not one to go around sounding alarms.  His articles are reasoned and insightful. SO it was with great concern that one of my IT people (shout-out Sean Nickerson) came into my office (my door is always open, insert Bob Newhart quip here).  He had just gotten an email with a link to the Nature story.

Here is a snippet:

There is still no evidence of any sustained human-to-human spread of the H7N9 virus. But the World Health Organisation confirmed on Saturday that Chinese authorities are investigating two suspicious clusters of human cases. Though these can arise by infection from a common source, they can also signal that limited human-to-human transmission has occurred.

"I think we need to be very, very concerned" about the latest developments, says Jeremy Farrar, director of the Oxford University Clinical Research Unit in Ho Chi Minh City, Vietnam.

....The Beijing Municipal Health Bureau also announced today that a 4-year-old contact of a 7-year-old girl who had been hospitalized with the virus tested positive for the virus too, despite showing no symptoms. (bold mine) This is the first asymptomatic case. Along with several mild cases already reported, it suggests that the virus might be more widespread among humans than the numbers of reported cases suggest.

Perhaps counterintuitively, such mild cases are "very worrying", says Farrar. That is because reduced virulence can often point to further genetic adaptation of the virus to infection of human beings — and thus greater potential to spread.

 Marc Lipsitch is an epidemiologist at the Harvard School of Public Health in Boston, Massachusetts. Declan quotes him:

"It's too soon to say how big a threat H7N9 poses because we don't know how many animals of which species have it, how genetically diverse it is, or what the geographic extent is," says Lipsitch, "It looks as though it will be at least as challenging as H5N1."

If you performed a Find and Replace using "H7N9" for "H5N1" in that blog post, you would instantly have a very topical blog.  So please read that blog from four years ago, and change the virus subtype in your head as you go along.

Now, I vector you to today's disclosure that 64 human H7N9 cases exist in six different provinces, including two fabled cases in the city of Beijing.  There are 14 deaths.  As I mentioned in one of my earliest blogs on the subject of human H7N9, barely a week ago:

Dr. Yin of the Bill and Melinda Gates Foundation.  Apparently Dr. Yin is the Foundation's leader in China.  And it was quite satisfying, knowing Bill and Melinda are spending funds in  China, including, but not limited to, surveillance.  Dr. Yin's statement is worth paraphrasing.  He said, basically, if you don't test for H7N9, you won't find it.  But if you do test for it, you'll find it.  The inference is that there have been numerous unexplained and undiagnosed severe respiratory ailments there this season.  Retroactive testing of samples, based on Dr. Yin's inference, will yield a significant increase in the number of H7N9 human cases. 

Indeed, with more than 400 labs across China testing away, they are finding more cases in more geographic locations.  Simultaneously, more deaths are being reported.  Fortunately, the deaths are not increasing in proportion to the number of confirmed cases.  We all believed that the case fatality rate would not be as high as the initial reports would have indicated; the sample was too low and the data, therefore, did not support (yet) a high CFR.

But I found it interesting that as of this morning, the WHO has not yet established a pandemic alert system for H7N9. Dedicated Web page, yes.  But the WHO has not started an alert system. 

WHO has an alert system in place for H5N1, and had one for pH1N1, a.k.a. The Virus Formerly Known As Swine Flu.  Perhaps it is too early for such an alert system.  After all, the virus is only in one region of one nation (albeit a region that is host to more than 300,000,000 Chinese).  I also understand the reluctance the WHO must feel regarding this disease.  The WHO took significant credibility hits after swine flu, some referring to the WHO as "chicken little."  These criticisms are unfair and undeserved.  No one had any idea that pH1N1 would have been as mild as it was.

And "mild" is a misnomer.  The words "mild virus" are of great consolation to virus experts, public policymakers and public health professionals who look at The Big Picture; but those words are of little consolation to the parents of children who died during the pandemic. 

A Reuters story from June of last year paints that smaller picture.

(Reuters) - The swine flu pandemic of 2009 killed an estimated 284,500 people, some 15 times the number confirmed by laboratory tests at the time, according to a new study by an international group of scientists.

The study, published on Tuesday in the London-based journal Lancet Infectious Diseases, said the toll might have been even higher - as many as 579,000 people.

The original count, compiled by the World Health Organization, put the number at 18,500....

The results paint a picture of a flu virus that did not treat all victims equally.

It killed two to three times as many of its victims in Africa as elsewhere. Overall, the virus infected children most (4 percent to 33 percent), adults moderately (0 to 22 percent of those 18 to 64) and the elderly hardly at all (0 to 4 percent).

Even though the elderly were more likely to die once infected, so few caught the virus that 80 percent of swine flu deaths were of people younger than 65.

In contrast, the elderly account for roughly 80 percent to 90 percent of deaths from seasonal influenza outbreaks. They were probably spared the worst of 2009 H1N1 because the virus resembled one that had circulated before 1957, meaning people alive then had developed some antibodies to it.

The relative youth of the victims meant that H1N1 stole more than three times as many years of life than typical seasonal flu: 9.7 million years of life lost compared to 2.8 million if it had targeted the elderly as seasonal flu does."

So swine flu was much more of a force than anyone (especially the critics) thought it was.

Here in April of 2013, we have a big problem.  No one knows how long this new H7N9 virus was circulating among wild birds, poultry and (especially) people in China.  In fact, we didn't know Diddley until March 31st, when the Chinese sprung the news upon the world.  Exactly when the Chinese knew it had H7N9 in people is cause for speculation, but I think we can excuse the Chinese for demanding confirmation before telling the whole world (to their credit) that a new pandemic candidate was emerging within their borders.

In fact, nothing may have ever been known, had the cases involving the three male family members not caused some doctor or technician to begin testing for something.  My guess is they speculated it was  seasonal influenza or H5N1 bird flu, then moved to SARS, then moved to the new novel coronavirus NCoV, and then reverse PCR testing revealed the presence of H7N9. 

Thank the Maker that someone had the curiosity and the desire to test in a wider spectrum!

Adding to the drama is the report from Beijing last week that a 4-year-old boy tested positive for H7N9.  He is not sick and displays no symptoms, yet he is an asymptomatic carrier of bird flu. This means wider testing is essential -- of humans, pigs and birds.  The testing net needs to be cast very widely in order for everyone to get their arms around the problem. 

And that, folks, is why I believe the USA's CDC opened its Emergency Operations Center at Level 2.  Since the CDC EOC alert levels only go from 3 to 1, the opening at Level 2 was considered by some to be controversial.

Knowing now what we do, and analyzing their decision in the current light, we should say this was an important and prudent decision.  Because, folks, we don't really know if this virus has come to America or not. And the only way we are going to know anytime soon is through weekly surveillance of mortality and morbidity.

From Wikipedia:

 United States

On April 9th, 2013 the Centers for Disease Control and Prevention (CDC) activated its Emergency Operations Center (EOC) in Atlanta at Level II, the second-highest level of alert.^[30] Activation was prompted because the novel H7N9 avian influenza virus has never been seen before in animals or humans and because reports from China have linked it to severe human disease. EOC activation will "ensure that internal connections are developed and maintained and that CDC staff are kept informed and up to date with regard to the changing situation."^[31]

From the Medscape article:

The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, received a specimen of the H7N9 virus from China yesterday. On April 9, the CDC activated the Emergency Operation Center (EOC) at Level 2 (there are 3 levels, with 1 as the highest) to support the management of the emerging H7N9 situation, Sharon KD Hoskins, MPH, senior press officer at the CDC told Medscape Medical News in an email.

Researchers used real-time reverse-transcriptase-polymerase-chain-reaction assays, viral culturing, and sequence analyses to test the patients' respiratory specimens for influenza and other respiratory viruses.

....In an accompanying perspective, Timothy M. Uyeki, MD, MPH, MPP, and Nancy J. Cox, PhD, from the Influenza Division, National Center for Immunization and Respiratory Diseases at the CDC, commented on the article, noting that this outbreak "is of major public health significance."

"The hemagglutinin (HA) sequence data suggest that these H7N9 viruses are a low-pathogenic avian influenza A virus and that infection of wild birds and domestic poultry would therefore result in asymptomatic or mild avian disease, potentially leading to a 'silent' widespread epizootic in China and neighboring countries," Drs. Uyeki and Cox write. The HPAI H5N1 virus usually causes rapid death in infected chickens.

I am not certain, but I am pretty confident that most labs in the United States are currently incapable of subtyping anything other than the prevaling seasonal flus of pH1N1, H3N2, B, and swine H3N2 (nice call, CDC). Anything other than these substrains are lumped into one or more catagories of A: "Subtyping not performed," or A "Unable to subtype."   However, the CDC is also beginning to catalog incidences of other novel influenzas.  From their April 6th report:

Novel Influenza A Virus

No new human infections with novel influenza A viruses in the United States were reported to CDC during week 14.

A total of 312 infections with variant influenza viruses (308 H3N2v viruses, 3 H1N2v viruses, and 1 H1N1v virus) have been reported from 11 states since July 2012. More information about H3N2v infections can be found at http://www.cdc.gov/flu/swineflu/h3n2v-cases.htm.

Assuming few, if any, US labs can currently quickly detect H7N9 bird flu, the only other capability the CDC has is to monitor and initiate surveillance of the public's health.  This means both ramping up a central monitoring presence dealing with day-to-day issues, and also ramping up state health departments to begin watching for unusual spikes in ILI, or Influenza-Like-Illness.

By activating their EOC at level 2, the CDC is able to pull in disparate elements and to begin the process of surveillance in earnest. Things you just cannot do sitting at a desk, you can do in a central coordinating facility, open-air, with people at their posts.  Having been in the State of Florida EOC many times, including pandemic exercises, actual hurricane tracking and the afternoon of 9/11 (and for days afterward), the ability to sort information and make decisions does not happen in a better environment.

On April 2nd, I formally activated the State of Florida CIO Association's Pandemic Committee.  It had stood in informal recess since the Swine Flu pandemic was declared over in 2010.  However, I decided that once the chickens were not doing their duty and dying, we had a real conundrum on our hands!

In fact, just last week, the Florida Department of Health announced that they were beginning monitoring the China H7N9 situation.  I suspect other state health organizations are ramping up, if for no other reason than to give the CDC timely and accurate information, should there be spikes in respiratory illness.

So what would a spike look like?  The spike would look something like this:

  
Hmmm.  This is the actual CDC Pneumonia and Influenza Mortality chart for April 6th, 2013. 

The top black line represents the epidemic threshhold.  The bottom black line represents the seasonal baseline.

The red line represents the actual reported cases.  As you can see, the red line is at the highest point since a spike at the beginning of calendar 2011, six months after the end of the Swine Flu Pandemic. In fact, the chart had suddenly spiked to a level higher than at any point since 2009.

Not sure of what was going on, but knowing this occurred before my rebirth as a flu blogger, I reached out to Mike Coston (again). I asked Mike about what had happened? 

Mike told me that the CDC immediately looked into the situation. In fact, he blogged on both the mortality spike and the CDC's response. Apparently, what happened is that H3N2 drifted.  If you need a primer on antigenic shift vs. antigenic drift, click here.

Anyway, what happened is that, apparently, the H3N2 seasonal flu drifted.  And seniors, who may not have been vaccinated as often as recommended, had no immunity to the drifted virus -- immunity they might have had, if they had goten regular flu shots.  H3N2 is a nasty bug for anyone, but especially for the elderly, who died in numbers sufficient to trigger the uptick that you just saw.

A similar uptick, especially coming now as flu season wanes, would trigger a pretty quick CDC response.  This is why the CDC activated.  This is why state departments of health are getting ready to ramap up their surveillance. 

To recap:

• The chickens are not doing their duty and dying.
• China has no real idea how widespread the virus is.
• Nobody else does, either.
• There is currently no reason to suspect there is H7N9 in North America.
• That having been said, there is always the possibility that infected, asymptomatic travelers have come into the United States via any of the Pacific ports of call and airports. Unlikely, but not impossible.
• Certainly, we would have seen the virus in Hong Kong before we would have seen it here.
• Currently, there is no inexpensive, routine way to test in doctors' offices or public health departments in the USA for H7N9. 
• H7N9 would appear as "Type A, Unable to subtype" or "Type A, subtyping not performed."
• We have a long way to go with this situation.