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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?

It was a busy weekend.  While America and Boston began its recovery from the horrible events of the preceding days, the situation in China worsened.

"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.

In a conference call this afternoon with clinicians, the U.S. Centers for Disease Control and Prevention has officially asked hospitals and doctors to begin looking for signs of human infection with H7N9 avian flu.

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.