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OK, THIS is unsettling.  Prior to this week, I only knew Dothan as the city where my parents were married, and where my wife, stepson and I would stop on the way to Tuscaloosa during his recruitment by the Crimson Tide. Dothan is about a two-hour drive from Tallahassee, in southeastern Alabama.  It is a large town, and a crossroads for persons traveling from Interstate 10 to Interstates 65 or I-85.

But now, Dothan is known as the epicenter of an outbreak of a still-unknown respiratory outbreak.  And forgive me if it is a bit worrisome to me on several levels.

First, the situation on the ground here in Tallahassee:  I am on Month 5 of some sort of mystery ailment.  It is, apparently, some sort of allergy, brought on by (I theorize) an Alien Spore Cloud of some magnitude.  I say this because, roughly, 2000% of Tallahasseans are suffering as well.

A couple of weeks ago, I traveled with my beautiful wife to a conference she was working in Cocoa Beach.  I was able to get some quality body-surfing time, although my "rescue" at the hands of misguided marine biologists who misinterpreted my body surfing as the throes of a beached whale was not appreciated.  Just kidding on that one.  I said to myself, "Self, this salt air and seawater should wipe out whatever it is in my sinuses that is causing me Hell." 

WRONG!  later that day, I restarted my routine of sneezing and dealing with a runny nose.

It seems that every other Tallahassean, including my wife, is suffering the same fate. So you can see where a respiratory incident could easily be misinterpreted -- until people stop breathing, that is.

Back to the Dothan cluster.  From the Alabama Department of Public Health, dated 5/21/13:

 On 5/16/13, a pulmonologist in Southeast Alabama reported to the Alabama Department of Public Health (ADPH) that three patients had been hospitalized with cough, shortness of breath, and pneumonia, were on ventilators, and had no known cause for their illness. The ADPH and the Houston County Health Department began an epidemiology investigation to interview the families about travel and exposure. Specimens were requested and submitted to the ADPH Bureau of Clinical Laboratories (BCL) in Montgomery.

On 5/17/13, BCL reported one of the three patients tested positive for 2009 H1N1. On 5/18/13, this patient died. On 5/19/13, the same hospital reported that a transferred patient on a ventilator with respiratory symptoms had died. On 5/19/13, this hospital had nine additional patients present to the emergency department with influenza-like illness and three of those patients were admitted. Specimens have been collected on all patients. The BCL has tested all specimens on a PCR flu panel and one tested positive for AH3. The specimens were also forwarded to CDC for additional testing.

The story gets more interesting, as three additional residents have been diagnosed with -- whatever.  From Montgomery, Alabama television station WSFA 12:

HOUSTON CO., AL (WSFA) -

The number of mystery illness cases affecting Alabama is growing. Wednesday, Alabama Department of Public Health spokeswoman Dr. Mary McIntyre confirmed the number rose to ten overnight from a previous report of seven. Two people have died.

"Since we sent out the alert to providers last night, we have had three additional patients/cases," Dr. McIntyre told WSFA 12 News. "These patients all have the same symptoms of cough, shortness of breath and "something" on their chest x-rays," she explained.

Of interest is the fact two of the afflicted -- including one of the deaths -- tested positive for influenza.  One of the deceased tested positive for H1N1, and another patient tested positive for A/H3. Whether this was seasonal H3N2 or swine H3N2 is not known.  My hunch is it is the more virulent form of H3N2 that we saw at the tail end of this flu season.  That caused such a spike in elderly deaths that it prompted the CDC to do a pretty exhaustive analysis -- the spike in deaths was that great.

This incident might not have generated the corresponding amount of publicity, were it not for the vigilance in the face of H7N9.  H7N9, by the way, seems to have taken a vacation. 

Of the original seven cases, three remain hospitalized.  Two were discharged, and two met their Maker.

ABC News theorizes that these cases may not be a cluster of anything except overreaction. However, we know that three people are still on ventilators and the community is on pins and needles.

NBC News reports that Alabama health officials are not taking any undue chances.  While I doubt the medical facilities have any negative air-pressure rooms (we are talking rural Alabama here), they are taking all the precautions they can:

The hospital is using respiratory precautions, which include requiring staff to wear special N95 masks that reduce the chance of infection.

With H7N9, MERS-CoV and God knows what else out there, no one is taking any chances.  The CDC is a three-and-a-half-hour road trip away; close enough to spend quality time in Dothan.  

First, let's catch up on the news of the day.  The first case of H7N9 off the Chinese mainland has been confirmed by Taiwanese officials.  In today's Hell Freezes over installment, the Taiwanese and Chinese are working together to track and attempt to contain this new bird flu. The blog, from Crof, can be found here.

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.

It takes a lot of chutzpah to derail a press conference anywhere, let alone China.  This is for the obvious reasons (gulag, inprisonment, execution, torture, etc.).

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.

The Australian virologist Dr. Ian Mackay's blog, Virology Down Under, is a great place to go to read -- and see the visual representatio nof -- the latest on H7N9. It has become one of my "go-to" sites for updates and assumptions.

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

 

WHO spokesperson Gregory Hartl recently spoke of the difficulties in pinpointing the vector of human transmission of H7N9. This is from an Investor Business Times article from last Thursday:

“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?