H7N9 bird flu: what we know and don't know

The story broke in China on April 1st: a new bird flu strain, called H7N9, had emerged to infect people for the first time.

At the time, there were three known patients, two of whom were already dead. Two weeks later, the case tally continues to grow at a clipped and steady pace. The latest count, from the World Health Organization: 82 cases, 17 deaths.

H7N9 has now spread to six different provinces -- most cases are in the Shanghai area, but cases have also been confirmed in Beijing and Henan.

Source: European Centre for Disease Control and Prevention (updated as of April 15)

It can be difficult knowing how much to worry when something like this unfolds. But for now, this tweet from WHO spokesperson Gregory Hartl -- who has been actively answering H7N9 questions on Twitter -- seems to best summarize the current situation:

We are not near a #H7N9 pandemic yet but we need to understand better how the virus works in order to control the outbreak. @who

— Gregory Härtl (@HaertlG) April 16, 2013

Not exactly reassuring -- but honest. Anything's still possible.

Given the information available so far, there is both reason to worry and reason for optimism. Here's a round-up of what we know:

The good news

*The single most reassuring piece of information right now is that there is still no evidence of sustained human-to-human transmission, which would certainly propel us into pandemic territory. There are, however, suspected cases of limited human-to-human spread that investigators are looking into -- but as the U.S. Centers for Disease Control and Prevention explains, this is not wholly unexpected and limited human-to-human transmission does not automatically mean a pandemic is nigh.

*H7N9 has not yet been found in pigs -- considered ideal "mixing bowls" for pandemic-prone viruses -- and health officials insist the dead pigs floating along the Huangpu river did not die by H7N9's hand. That being said, only 30-some pigs were ultimately tested out of more than 16,000 carcasses and the cause of these pig deaths remains a mystery. To date, the virus appears to be confined to poultry markets and has turned up in "environmental samples" as well as chickens, ducks and one wild pigeon.

*Some patients are improving or have even fully recovered, including Beijing's first case, a seven-year-old girl.

*China has invited the WHO and international experts to help with the outbreak response, including some top names in the infectious disease world. Labs around the world have also now received the virus and are busy studying its properties.

The bad news

*The world is in completely "new territory" with this new virus, according to this Canadian Press interview with WHO's senior flu expert. And there are troubling signs the virus is already well-adapted to infecting humans.

*We still have no idea what the source of the virus is despite the 48,000+ samples that have been taken from markets, farms and slaughterhouses. Are people being infected by chickens? Ducks? Pigeons? Some other bird? A still-unidentified mammal? Dust in the air? Other people? All of the above? China's Centre for Disease Control has also stated that 40 per cent of the known cases have had no contact with poultry, thus deepening the mystery of how people are getting sick.

*Unlike other avian flu strains that have caused human infections, H7N9 doesn't seem to make birds sick. This means the virus can spread silently among birds and will be difficult to stamp out through culling -- and if the virus is getting picked up by wild birds, there's no telling how far H7N9 can travel. As Nature reports, H7N9 is "poised to spread."

*The virus has now been found in a four-year-old Beijing boy who has no symptoms, making him H7N9's first known asymptomatic case. The excellent Avian Flu Diary blog has a good explainer for why this is not necessarily good news.

*Judging from a study recently published in the New England Journal of Medicine, this new bird flu strain can make people very, very sick.

*Creating a vaccine for this new flu strain will likely be very difficult.

Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. Follow her on Twitter: @jyangstar

Chinese growth rate slips, world markets react

In 1979, Shenzhen was a small fishing village with a population of 20,000. Now it is rated 5th in the world in terms of population density of over 10 million people. (Randy Risling/Toronto Star)

After years of growth, the surging Chinese economy has started to run out of steam.

For the first quarter of 2013, the Chinese economy grew only 7.7 per cent. Many analysts predicted a consistent 8 per cent growth rate for China -- a country which is edging out the United States as the world's biggest economy.

A slow-down in the manufacturing sector and overall global sluggishness is partly to blame for the slip.

The Financial Times reports that China's new premier, Li Keqiang, admits the future is unclear.

“Overall, the Chinese economy had a smooth start in 2013. But many uncertainties, both at home and abroad, still persist and make the overall situation quite complicated,” Keqiang said.

New York markets reacted to the downturn this morning as commodities fell to a nine-month low, followed by gold and silver tumbling.

According to Bloomberg, the Standard & Poor’s gauge of 24 raw materials dropped 1.4 per cent  in New York after silver tumbled more than 11 per cent and gold traded below $1,400 an ounce.

"The international situation continues to concern people, both in regard to Europe and China," Boston-based fund manager John Carey told Bloomberg. "People are watching for some signs of improvement in both areas."

Tanya Talaga is the Star's global economics reporter. Follow her on Twitter @tanyatalaga

 

Bear bile farm puts off stock market launch

A bear rescued from a bile farm, now living in a sanctuary in China. (Photo: Animals Asia)

A Chinese bear bile farm is putting off its stock market launch.

For now.

Guizhentang Pharmaceutical Company said the delay in their IPO is the result of needing more time to prepare the required information. It had been expected to file financial reports to the China Securities Regulatory Commission (CSRC) before May 13.

The company has encountered many difficulties since it first applied two years ago. Animals Asia, an agency that works in China, says these difficulties may reflect that neither the financial community nor the general public would support the listing of a company that extracts bile from live bears.

“Although we understand this is not a final withdrawal from the application process, it appears that Guizhentang has chosen to quietly withdraw from this confrontation between profit and animal welfare,” said Animals Asia.  

The bear bile trade sees over 10,000 bears — mainly moon bears but also sun bears and brown bears — kept on farms in China, North Korea and Vietnam. The bears are "milked" regularly for their bile, which is used for traditional medicine.

According to reports, bile is usually extracted twice a day through an implanted tube; the process is believed to be painful as the bears moan and chew their paws while being "milked" for their bile.

Traditionally, bear bile was extracted by killing a wild animal and removing its gallbladder. But in the 1980s, bile farms began appearing in North Korea and eventually spread to other regions.

The Asian black bear, most commonly seen on farms, is listed as vulnerable on the World Conservation Union’s Red List of Threatened Animals.

Guizhentang announced in February 2011 that it would raise funds through a public listing and increase its number of bears from 400 to 1,200.

There are about 240 bear bile farms in China.

Raveena Aulakh is the Star's environment reporter. She is intrigued by climate change and its impact, now and long-term. Follow her on Twitter @raveenaaulakh

Why badminton-crazed Indonesia is feeling the effects of bird flu in China

An official holds a chicken during a poultry check at the border with mainland China in Hong Kong on Thursday. (Philippe Lopez/AFP/Getty Images)

Any new outbreak like the H7N9 situation unfolding in eastern China is bound to be disruptive. To date, there have been 38 confirmed cases and 10 deaths, according to the latest update from the WHO, and predictably, there are now reports of busy hospitals, suffering airlines, falling stock prices and, of course, the thousands of poultry now being slaughtered as public health officials try to stem the outbreak. KFC in China is apparently also taking a hit -- as are McDonald's McNugget meals.

But there are other, less obvious ripple effects when a new virus suddenly pops up and causes widespread alarm. A few examples:

• sales of isatis roots, used in herbal remedies, have "skyrocketed" in Fujian, China, according to China Daily

• a sudden share boost for Malaysian rubber glove makers, according to Borneo Post
  

• a feared shuttlecock shortage in "badminton-crazy Indonesia," which imports dried duck feathers from China for its shuttlecocks, according to this Agence France-Presse story

Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. Follow her on Twitter: @jyangstar

As bird flu cases mount, a new tool for containing global outbreaks

Source: St. Michael's Hospital

Another day, another handful of new H7N9 cases, another death to report in eastern China.

The new bird flu strain continues to puzzle and alarm health officials in China and around the world. But thankfully, H7N9 isn't spreading easily between people -- yet.

Public health authorities are tightly crossing their fingers that the virus fails to mutate into a more dangerous form and will eventually just sputter out. The fear is that it will evolve into something more infectious -- like H1N1, which popped up in Mexico and caused a pandemic in 2009.

Luckily, H1N1 wound up being a pretty wimpy virus and caused mostly just mild disease -- but from the looks of it, an H7N9 pandemic would prove much more devastating.

You can bet public health officials worldwide are already preparing for that eventuality, which is why there is no better timing for this new paper, published in the Bulletin of the World Health Organization.

The paper comes from a group of scientists led by Dr. Kamran Khan, an infectious disease physician at St. Michael's Hospital and founder of BioDiaspora, a really interesting program that uses global flight patterns to predict the spread of new infectious diseases. (Khan spoke to the Toronto Star earlier this week about the likelihood of an H7N9-infected traveller from China coming to Canada -- for now, the chances of that are pretty low).

When outbreaks hit, public health officials have to make difficult but necessary decisions to prevent a virus from spreading further. They might consider airport screening, for instance -- but such measures should not be taken lightly, because they are hugely disruptive and require major resources.

So such actions need to have a strong scientific basis -- and that's where Khan's paper comes in. Looking at the 2009 H1N1 pandemic, Khan and his co-authors analyzed flight itineraries for more than 580,000 at-risk travellers who flew out of Mexico in May 2009.

They concluded it is much more efficient to screen passengers exiting an outbreak country than those arriving at their destination airports. According to Khan's estimates, all at-risk travellers during H1N1 could have been assessed with exit screening at Mexico's 36 international airports.

And 90 per cent of all at-risk travellers worldwide could have been captured by screening at just six of Mexico's largest international airports, coupled with targeted screening at two airports in Shanghai and Tokyo.

On the other hand, trying to screen those same travellers when they arrived at their destination airports would have required setting up checkpoints at 82 international airports in 26 countries.

And screening all international travellers at their arrival destinations would have been staggeringly difficult. During the H1N1 pandemic, this would have meant screening 67.3 million grumpy travellers at 1,111 airports -- and for every one person who actually had exposure to H1N1, 116 people would have been unnecessarily screened.

Using their findings, Khan and his co-authors developed a basic tool to help public health officials decide whether, and how, to set up airport screening. The tool takes three things into account: 1) whether there is effective exit screening at the source of the outbreak 2) whether a city receives direct flights from the outbreak country 3) the incubation period of the disease.

"One never waits for a fire to spread before putting it out," Khan said in a press release. For now, the H7N9 situation is just a few dozen sparks in eastern China -- let's hope it doesn't become a flame we have to snuff out.

Update: Canadian Press reporter Helen Branswell has written a great article about Khan's study, which has now been posted on the Toronto Star's website here.

Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. Follow her on Twitter: @jyangstar

Chinese thirst for infant formula reaches U.K.

Chinese parents, desperate to access powdered milk that is not tainted, appear to be the reason why supermarkets in the United Kingdom have been asked to restrict sales of baby formula.

The Guardian is reporting Tuesday that there is evidence the products are being bought in bulk for “unofficial export” to China.

Danone wants grocery stores to restrict sales to two 900g tins per customer. Apparently, the formula has been flying off the shelves and being sold online.

In a statement, Danone said they “understand that the increased demand is being fuelled by unofficial exports to China to satisfy the needs of parents who want Western brands for their babies.

“We would like to apologize to parents for any inconvenience caused by this limit. We know that most parents only buy one pack at a time, so we hope that the impact of this limit on U.K. parents will be minimal,” the statement said.

Australia has also rationed powdered milk sales, the BBC reports.

As previously reported in our World Daily blog, powdered milk sold in Hong Kong stores has been in hot demand on the mainland since six children died and nearly 300,000 sickened from melamine laced milk in 2008.

And last year, China’s biggest milk producer, Inner Mongolia Yili Industrial Group was forced to recall formula tainted with mercury, Reuters reports.

Chinese authorities have had to restrict how much formula can be brought into the mainland and they’ve imposed stiff penalties of two years in prison or up to $80,000 in fines if anyone is caught smuggling in more than is allowed.

READ MORE: Hong Kong limits baby formula trade as anger grows over hoarding by mainland Chinese traders

Tanya Talaga is the Star's global economics reporter. Follow her on Twitter @tanyatalaga

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In other bird flu news...

A bird flu strain called H7N9 has been dominating headlines lately, and with good reason. The strain, which has never been known to infect people before, has suddenly begun popping up in eastern China, where it has now killed eight people. So far, there have been 24 confirmed cases but the tally is steadily rising by the day. 

But yesterday, another bird flu strain was quietly in the news: H5N1, which — until H7N9 came along — was the most notorious of the bird flu strains.

This story came out of eastern Bangladesh, where a two-year-old baby died of H5N1 — making him the country's first known fatality from bird flu.

H5N1 made its world debut in 1996 when a poultry outbreak in Hong Kong wound up killing six people. The region's entire chicken population was slaughtered but that didn't stop the virus from spreading amongst birds — and infecting people in other parts of the world. Today, human cases have been recorded everywhere from Vietnam and Cambodia to Nigeria, Turkey, Egypt and, now, Bangladesh, which has seen six cases since 2008, five from the last two years. In a decade, 622 people have been infected with H5N1 and 371 have died — a fatality rate of about 60 per cent.

For infectious disease experts now watching H7N9, that other bird flu is likely haunting their thoughts. Even if H7N9 doesn't become easily transmissible between humans (the nightmare scenario), it may very well follow in H5N1's footsteps and continue spreading in bird populations — thus turning H7N1 into a global terror, always lurking and threatening to pop up. Or, even worse, mutate into a more dangerous form.

But there is one key difference between H7N9 and H5N1 that makes the former even more concerning —  unlike H5N1, which decimates entire chicken flocks, H7N9 doesn't seem to make birds sick, meaning it can spread undetected. If H7N9 does start flying around the world, we will have a hard time noticing — that is, until people in other corners of the world start getting sick.

Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. Follow her on Twitter: @jyangstar

The Chinese have yuan and will travel

The Chinese are now the top travel spenders in the world. (Reuters)

While many folks continue to nervously watch their dollars and euros go down the drain, those from mainland China are out spending and travelling the world.

China’s expenditure on foreign travel was $102 billion (U.S.) in 2012, the United Nations World Tourism Organization reported on Thursday.

A growing Chinese middle class and an ease on travel restrictions is behind the surge, the report notes. In 2000, only 10 million Chinese travellers were criss-crossing the globe. By 2012, the number leapt to 83 million, the report said.

Behind them are the Germans who spent $83.8 billion U.S. on travel abroad, the Americans at $83.7 billion, the British at $52.3 billion, the Russians at $42.8 billion, the French at $38.1 billion and the Canadians at $35.2 billion.

The Japanese come in eighth on the list of the world’s top tourism spenders, dishing out $28.1 billion in 2012.

What’s clear is the emerging economies continue to lead growth in tourism demand, UNWTO Secretary-General Taleb Rifai commented in a release.

“The impressive growth of tourism expenditure from China and Russia reflects the entry into the tourism market of a growing middle class from these countries, which will surely continue to change the map of world tourism,” he said.

Tanya Talaga is the Star's global economics reporter. Follow her on twitter @tanyatalaga

 

H7N9 bird flu: is Canada ready for a bird flu outbreak?

Chinese health workers collect bags of dead chickens at the Huhuai wholesale agricultural market in Shanghai on April 5. (AFP/Getty Images)

As the world nervously watches the bird flu outbreak unfolding in China, two questions are likely at the top of everyone's minds:

1) Will H7N9 start spreading between humans?

2) Will it come here?

The WHO has confirmed 16 cases so far, including six deaths. They also announced today that any new H7N9 updates will be announced on their Twitter account first. It is important to note, however, that there is still no evidence of human-to-human transmission and the prevailing theory is that people are getting infected by poultry.

But now there are also a few suspected imported cases of H7N9 in Hong Kong and, according to Chinese reports, in Taiwan -- both involving people who have recently visited China. This is not altogether surprising, considering the close ties and proximity between those countries and China.

But could there be imported cases in Canada? It's hard to know but the possibility certainly cannot be ruled out. There is a huge Chinese population in Canada and during the SARS outbreak in 2003, we were among the countries hardest hit -- we were also completely caught off guard by the sudden appearance of a brand new virus (for a refresher, you can read my colleague Amy Dempsey's recent SARS anniversary stories here and here).

So if an H7N9-infected person were to arrive on our shores, is Canada ready to test for it? The Public Health Agency of Canada's National Microbiology Lab says yes. Here's what they told me by email: 

How is the Agency able to detect the H7N9 virus?

The Agency's National Microbiology Laboratory has access to the H7N9 whole genome sequence through the Global Initiative on Sharing Avian Influenza Data. With this information, the NML has the capability to rapidly detect the H7N9 virus.

Can the provincial laboratories detect the virus?

The NML is working closely with provincial laboratories to ensure they will soon be able to test for the H7N9 virus.

How is the Agency monitoring the situation in China?

An Agency medical expert is based in Beijing, and is liaising with the Chinese infectious disease prevention authorities on this outbreak. The Agency is also continually monitoring information on avian influenza H7N9 in poultry, as well as human cases in China and is working closely with its national and international partners, including the World Health Organization, to track all types of flu activity in Canada and around the world.   

It will be really important for provincial labs to acquire the capacity to test for the new bird flu strain, however -- as of now, any samples from a suspected case in Canada would have to be shipped to Winnipeg for testing and confirmation (although even after the provincial labs acquire the capacity to test, any positive cases would be doubly-confirmed by the Winnipeg lab, at least in the early stages).

A spokesperson with Ontario's public health lab tells me they currently have tests that can pick up Influenza A, which would flag the sample as a suspected H7N9 case. As of yet, however, they do not have specific tests to pick up H7N9 -- they're working on that right now.

Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. Follow her on Twitter: @jyangstar

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Bird flu: More cases, more rumours in China's spreading outbreak

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Bird flu: More cases, more rumours in China's spreading outbreak

A woman at a chicken farm in Zouping, east China's Shandong province on Monday. (AFP/GETTY IMAGES)

Rumours have been coming fast and furious in the wake of Sunday's announcement that a new bird flu strain, H7N9, has infected humans for the first time (that we know of, that is). Two men in Shanghai have died; a woman in Anhui province, some 360 kilometres away, has also fallen ill and is now in critical condition.

Earlier Tuesday, a picture was making the rounds on Twitter and Chinese media, allegedly a patient's diagnosis sheet leaked by a hospital staffer in Nanjing, capital of Jiangsu province. The person posted the picture on Chinese social networking website Weibo and said the patient was a 45-year-old poultry butcher who was confirmed as having H7N9 on March 30.

That information remains unconfirmed but now it looks like we have official word of four more cases from four different cities in Jiangsu province -- including a 45-year-old poultry butcher. Jiangsu's health department has posted a Chinese-language press release on their website announcing the additional cases -- which have not yet been confirmed by the World Health Organization.

According to a machine-translated version of the Chinese announcement, the new patients are:

* A 45-year-old female from Jiangning District who worked with poultry. She developed symptoms (fever, dizziness, body aches, fatigue) on March 19; on March 27, she went into ICU. Currently in critical condition. The Chinese CDC tested her today and she was positive for H7N9. Officials are now monitoring 49 people who have come into contact with her; none are showing any symptoms yet.

* A 48-year-old woman who worked in "sheet metal processing." Developed symptoms on March 19 and was transferred to ICU on March 30 at Nanjing Hospital. Currently in critical condition. Was confirmed to have H7N9 today by the Chinese CDC. Officials are now tracing 60 people who have come into close contact with the patient; none have any symptoms.

*83-year-old male from Suzhou Wujiang District. Developed symptoms on March 20 and was transferred to hospital on March 29. Tested positive for H7N9 on April 1. Officials are now following 15 contacts of this patient; none have yet to show any symptoms.

* A 32-year-old unemplyed woman who lives in Wuxi city. Developed symptoms on March 21 and was transferred to a hospital on March 28. She was confirmed to have H7N9 on March 31 by Jiangsu health authorities, a diagnosis that was confirmed on April 2. Health officials are monitoring 43 people who've come into contact with the patient; none have respiratory symptoms.

There are apparently no epidemiological links between the four Jiangsu cases.

Update: Some information on what Chinese authorities are doing to step up their outbreak response, from an Associated Press report by Gillian Wong:

The provincial health bureau said it was strengthening measures to monitor suspicious cases and urged the public to stay calm, joining Beijing and China's financial capital, Shanghai, in rolling out new steps to respond to the relatively unknown virus.

The latest cases follow the three earlier ones reported Sunday, including two men who died in Shanghai, resulting in the city activating an emergency plan that calls for heightened monitoring of suspicious flu cases. Under the contingency plan, schools, hospitals and retirement facilities are to be on the alert for fevers, and administrators are to report to health authorities if there are more than five cases of flu in a week.

Cases of severe pneumonia with unclear causes are to be reported daily by hospitals to health bureaus, up from the weekly norm. The plan also called for stronger monitoring of people who work at poultry farms or are exposed to birds.

The level-3 response plan, the second-lowest in a four-stage scale, reflects higher concern after the H7N9 bird flu virus led to the deaths in Shanghai and seriously sickened a woman in the city of Chuzhou 360 kilometres west.

"The health bureau will take effective and powerful measures to prevent and control the disease, to make sure the flu epidemic is effectively guarded against and to safeguard the health of the city's residents," said Xu Jianguang, head of the Shanghai Health Bureau.

Health officials said this week there was no evidence that any of the three earlier cases, who were infected over the past two months, had contracted the disease from each other, and no sign of infection in the 88 people who had closest contact with them.

Health authorities in Beijing also upped the capital's state of readiness, ordering hospitals to monitor for cases of bird flu and pneumonia without clear causes, the official Xinhua News Agency reported.

The announcements, as lacking in details as they are, show that the government is mildly more transparent in handling health crises than it was a decade ago during the SARS pneumonia epidemic. Then, as rumours circulated for weeks of an outbreak of an unidentified disease in southern Guangdong province, government silence contributed to the spread of the virus to many parts of China and to two dozen other countries.

Scientists are closely monitoring these viruses for fear they could mutate into a strain that easy spreads among people, but there's no evidence of that occurring.

Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. Follow her on Twitter: @jyangstar