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Taiwan reports first H7N9 case -- with complications.

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:


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.


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