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The Chinese are reacting to both the introduction of H7N9 into humans, and the fact that birds are not showing symptoms as they usually do. 

The Chinese have ordered the culling of poultry in the city of Shanghai.  A live bird market has been ordered culled of anything with feathers.  Specifically, according to the Chinese news service Xinhua, it was the Huhuai wholesale agricultural products market in the Songjiang district of Shanghai.

The article can be found here. And a huge hat-tip to my friend and birthday boy Mike Coston.

In the meantime, it appears a contact of one of the H7N9 confirmed fatalities has gotten sick. The entire world press corps will be camped at that hospital while we openly wonder if H2H has begun.

The news today brings two more cases of human infection with H7N9 avian flu, and the confirmation of the fourth death I mentioned in yesterday's blog. 

WAIT!  NEWS FLASH!  Now, according to Treyfish, veteran Flutrackers poster, China has reported 14 cases of human H7N9 infection. And one pigeon.  Five humans are dead.  The pigeon's status is uncertain.

I am only half-joking when I mention the pigeon.  As I blogged yesterday, birds appear to be unaffected by this bird flu.  Ordinarily, when a bird has bird flu, it gets very sick and then dies. 

As ESPN celebrity and former FSU player Lee Corso would say, not so fast, my friend. This bird flu is not making birds sick.  If it were, we would have seen H7N9 coming.

Now, Corso did not say that about bird flu.  I said that.

At least one of the two newly-reported cases is in Zhejiang Province.  This province has previously reported cases of H7N9 recently.  Please refer to the map of Chinese provinces I posted in a previous H7N9 blog. The location of the second new case today is not confirmed.

There is feverish (so to speak) activity taking place among those who know the genetics of influenza. These intrepid individuals have been studying the anatomy of H7N9 and sharing that data via the Internet.  The crowdsourcing of H7N9 data is most helpful and extremely important, for it allows a much greater number of qualified researchers to begin the process of dissecting this troubling new virus.

As one can imagine, samples of this new strain of H7N9 are rare.  I can only imagine the frantic process of obtaining these samples and sending them via fighter jet halfway around the world to ground transports, those transports, in turn, racing these samples to facilities such as St. Jude and Drs. Webster and Webby.  Well, that's how it would work in the movies. The reality is probably based around Fed Ex and UPS.  "Sign here for your lethal bird flu virus, Doctor Webster."

Anyway, you have eleven positive victims, and four deaths, and only so much tissue to go around.  So those lucky enough to have actually processed the samples themselves are able to post their research online.

We are a long, long way from being able to replicate things in a laboratory.  We are a long, long way from growing H7N9 in quantities sufficient to conduct any real experiments, with ferrets, birds, or any other creatures. So all we have right now are the phylogenetic charts showing the antecedents of H7N9, and where we have seen their individual component parts before. 

For example, GeneWurx, which posts to Flutrackers, says this about what they have seen:

Though H9N2 is regaled as the nearest relative on file for these internal gene segments of the H7N9 emerging zoonosis, note the highlighted areas including a fatal H5N1 human, pH1N1 in swine (with human homology) and sH3N2. These H7N9 sequences have developed from pedigrees not entirely disjunctive from human infection.

You will recall the (not so) little problem America had with its rural county fairs the past two summers.  People were petting farm animals and then winding up with swine H3N2. I really meant to blog about those cases.  Anyway, an excellent CIDRAP article from last October showed now closely related the swine H3N2 and the longtime seasonal human H3N2 were related.

The press has been running excerpts of an interview with Dr. Richard Webby, of St. Jude.  For new readers:  St. Jude has arguably the top influenza research facility in the world.  Its director, Dr. Robert Webster, is nicknamed the "Pope of Influenza."  Dr. Richard Webby works with Dr. Webster and he is also an email buddy of mine.  Dr. Webby said this to the press about H7N9:

"I think that's what's concerning about this ...This thing doesn't any longer look like a poultry virus," Webby, a swine flu expert, said in an interview.

"It really looks to me like it's adapted in a mammalian host somewhere."

If the virus is spreading in mammals, finding that source is critical to try to reduce human exposure and prevent additional cases, he said.

Also weighing in is Dr. Henry Niman.  Dr. Niman has composed an excellent map of the human cases so far, cases known and suspected.  He also is seeing the progression that Dr. Webby has seen, but he does have a rather flamboyant writing style:

The latest cases increase concerns that the presence of D225G and Q226L represents human adaption of a lethal bird flu virus that has a greater pandemic potential than H5N1.  This potention is enhanced by the presence of PB2 E627K.

Veteran readers of this Blog know that the presence of PB2 E627K signals a move away from avian proclivities and toward mammals.  These are the changes that worry researchers so much.  Also knowing that the birds are not dying means surveillance using conventional (and cheaper) methodology is out the window.  We need a better way to detect the presence of this new flu, and we need it quickly.

There is no question that, somewhere along the line, a pig -- or a human -- was the Mixing vessel that produced this new, novel and immensely troubling virus. 

Fasten your seat belt.

The H7N9 outbreak continues to grow.  This morning, both Flutrackers and Avian Flu Diary are reporting multiple Chinese stories that two new and previously unreported human H7N9 cases have been found in Hangzhou, Zhejiang Province.  Both cases have died.

The machine translation from Chinese to English can be problematic where date (well, pretty much anything else) is concerned, so it takes skill to parse correct dates from the rest of the dialogue.  Regrettably, that is a skill I lack.  But many others do, and these talented people are all located on Flutrackers.com.

There appear to be two separate dates of infection.  One apparently is the 7th of March, and the other is the 25th of March. But what is plain is that this brings a fourth province -- and third coastal province -- into the picture. By any yardstick, we have not yet defined the scope of this outbreak.  Although it appears human-to-human transmission may or may not yet be possible, and as we covered at length yesterday, H7 can and does infect humans, the cat appears to be out of the bag.

The biggest impediment to getting our arms around the scope of the crisis (yes, I consider this to be a crisis, because we have a novel strain of influenza that no one, outside a random poultry worker or hunter is immune to, and it is killing people):  It is not killing poultry.  Sentinel chickens (the proverbial canary in a coal mine), used to help detect the presence of avian influenza, may be asymptomatic carriers of the disease.  At least that is one oprevailing theory, which would also explain why and how this virus escaped surveillance and, thus, early detection. 

You always knew when H5N1 bird flu was close by:  You could follow the trail of dead and soon-to-be-dead chickens.  H7N9 is not killing chickens.  Nor, contrary to what our deepest nightmares and feelings might tell us, is it killing pigs. 

My blog of yesterday mentioned a 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. 

I am hopeful that the CDC here will start looking at the number of "A (subtyping not performed)" samples still lingering around. 

The world woke up Easter Sunday to some pretty unsettling news.  No, it was not about that twit in North Korea.  The news came out of China, and it hit hard enough for me to start blogging again. 

China is the source of a novel H7N9 influenza virus.  And the virus is infecting, and killing, humans.

In the past three years, I have written a small handful of infectious disease blogs.  I just felt that I had nothing to contribute; people such as my buddies Mike Coston, Crof and Maryn McKenna were filling that space quite nicely, and I could not offer anything of value.

Then, a few months ago, I began to formulate a concept in my mind.  Things were just too dang quiet, I thought.  H1N1 was still infecting and killing overseas, but H3N2 was the principal culprit in North America.  Odd, I thought:  Flu always plays King of the Mountain.  Why should a seasonal strain be more prevalent -- and also more deadly -- than the recent pandemic strain?

I looked at this novel coronavirus situation in the Middle East.  What the heck was going on with that?  As I began the research into this novel coronavirus, I thought what everyone else was thinking:  Is this the Next Big Pandemic?

And, as always, Mother Nature shows us who is boss.  She shows us that you simply cannot predict when something is going to pop up and take all us arrogant humans by the scruff of the neck and shake us and berate us for ever, ever thinking we know what is coming.

Here, in a capsule of a capsule, is what we know, as of 1PM EDT on the second of April, 2013.

Sometime in mid-February, a family of three Chinese men in Shanghai  -- an 87-year-old father, and two sons, aged 55 and 69 -- contracted something very, very virulent.  Two of the men died.  The lone survivor was hospitalized with pneumonia (alarm bell #1). The dead father was discovered to have had H7N9 influenza.  H7N9 was not found in the two sons. The younger son also died.  H7N9 was not found in him. The inescapable fact is that all three men suffered from terrible pneumonia, and two died.  As we all know, pneumonia is the most prevalent byproduct of influenza. No one is going on the record as stating, flatly, that the other two cases were not H7N9.  They are saying they did not detect any.  There is a difference.

In early March, about two hundred miles away, a 35-year-old woman contracted something very, very virulent. She, too, was diagnosed with H7N9 influenza (alarm bell #2).

It took the Chinese authorites until March 31st -- March 31st -- to disclose that, indeed, there was the presence of a novel influenza, never before seen in humans.  I suppose we should celebrate the fact the Chinese disclosed anything at all. And the Chinese are, apparently, doing their due diligence.  Some 88 contacts of the three men have been monitored, and to date, none have shown symptoms of respiratory distress.  That would seem to downplay the possibility of human-to-human transmission.

This would be all fine, well and good, except for one small fact:  We are getting reports of more cases. Just as I was fact-checking this blog, news arrived of four more cases, again disclosed by the Chinese government.  All the new cases come from a third province.  Quoting from the proMED dispatch:

The number of confirmed human cases of avian A(H7N9) influenza virus infection has now risen to 7; the number of fatalities remains at 2.

The condition of the 4 new cases is critical, and all remain in hospital. None of the 4 new cases are related to the previous 3 cases or to each other. Only one of the new cases has had daily contact with birds, a 45-year-old woman who is described as a poultry butcher. The pattern remains the same, presumptive direct infection from poultry and no evidence of person-to-person transmission. The overall situation is becoming more serious, suggesting that many people may be directly susceptible to a strain of avian A(H7N9) influenza virus that may be widespread in the avian population (wild or farmed) in China.

The consequences of infection by this virus appear to be severe. - Mod.CP

The number of human cases of infection via H7 influenzas is considerable. Mike Coston has constructed a nifty history of those infections in his recent blog post, so I will not attempt to replicate his fine post.  Suffice it to say that H7 is known to scientists and researchers, but (up to now) its ability to cause serious illness in humans, save for one hapless vet in the Netherlands a few years ago, is small.

Until now. 

Crawford Killian, the noted author and flu blogger, has an excellent post today.  The spource is an AP story on the outbreak.  It quotes a researcher from the Bill and Melinda Gates Foundation.

"When you don't look, you don't find them, but when you look, you'll find," said Dr. Ray Yip, a public health expert who heads the Bill and Melinda Gates Foundation in China. 

"A lot of people get severe respiratory conditions, pneumonias, so you usually don't test them. Now all of a sudden you get this new reported strain of flu and so people are going to submit more samples to test, [so] you're more likely to see more cases," Yip said. 

Sharon Sanders and the posters at Flutrackers are reporting some pretty weird events in Hebai Province, China.  First, let's locate Hebei on the map.

 A series of seemingly disassociated events, when viewed at a higher level (as Sharon has done in her Flutracker posts), paints a picture of Hebei as in some sort of state of emergency (my words).  Shops closed by force.  People required to wear masks.  A thousand police officers dispatched to maintain discipline.  And, in the most stark post yet, occupancy at the regional hospital exceeding 100% and an isolation ward erected.

Official (meaning government) reports coming from the region speak of the virus actually being Adenovirus 55, and not the dreaded (and rumored) SARS virus.  We know the Case Fatality Rate from SARS hovered, eventually, around 10% of the sick.  A hospital filled with a thousand sick would produce at least a hundred dead, if the virus were SARS.  Rumors and slim media accounts seem to converge on just one person dead so far.

What we know of Adenovirus 55 is limited, but growing.  A paper that was published in 2009speaks of the first (and until now, last) major outbreak of Ad55.  Ad55 will produce some serious respiratory distress, but blessedly, only one death in 254 infected Chinese students in Shaanxi Province, China.  Here's the map showing the location of Shaanxi:

As you see, Shaanxi is two provinces over from Hebei.  I do not think it would be much of a stretch to say that this entire region may want to re-evaluate all its respiratory distress cases and outbreaks since 2005 to see if Ad55, instead of flu, could be an explanation.

Of course, what fascinates me is that China was able to come up with a positive diagnosis of Ad55 so quickly.  Long-time readers of this Blog (if I still have any!) know that I have been campaigning for testing for Ad14, which has a long and ugly reputation in military bases all over America, and hospitals in the Pacific Northwest.  As the medical report from 2009 attests, a "tsunami" (their words) of genetic information relative to Adenovirus is pouring in to researchers.  Good!  Maybe we will begin to take Adenovirus more seriously. 

In the meantime, it is also interesting to see what lengths the Chinese government will go to try to isolate anything that even remotely resembles SARS.  The government's zeal to prevent or mitigate the spread of an infectious disease is "disconcertingly refreshing."  Feel free to use that phrase.  It is troubling, no doubt, to see government trucks rolling into a province, and that has to evoke bad memories for the residents.  From a global perspective, however, and especially in light of the aftereffects of the film "Contagion," any attempt to contain a pathogen and prevent it from spreading is  appreciated, as long as the actions are 1) justified, 2) non-lethal, and 3) abandoned, once the pathogen is proved to be relatively harmless.