This completes the provinces surrounding the highly active Zhejiang province.
New insight into testing and epidemiology of infection.
In an excellent new article in the Lancet, Chen and colleagues explain testing (sensitive real-time RT-PCR for M, H7 and H9 targets; culture on MDCK (canine) cells to grow virus) describing result from throat and sputum samples from 4 patients.
They associate human cases directly to epidemiologically linked chickens (also tested quail, pigeons and ducks) samples from "wet" market (traditional live animals with on-site butchery - water used to clean up).
They associate human cases directly to epidemiologically linked chickens (also tested quail, pigeons and ducks) samples from "wet" market (traditional live animals with on-site butchery - water used to clean up).
Infectious and Cerebrovascular Diseases in Peru
Shibani Mukerji
PGY-3, Partner's Neurology
As in many South American countries, Peru has a wealth of patients with neuroinfectious diseases. In Lima, there appears to be a disproportionate number of neurologists available to help with their diagnosis in comparison to the rest of the country. Peru has 254 neurologists registered with the Peruvian Medical Association (approx. 1 neurologist per 119,980 people) and nearly 73% of them work in Lima.
Navarro-Chumbes et. al, Neurol Int. 2010 June 21; 2(1)
The Instituto Nacional de Ciencias Neurologicas (INCN, http://www.icn.minsa.gob.pe/) is both an inpatient hospital with outpatient clinics that specializes in adult and pediatrics neurology. I spent the majority of the last week in their infectious disease ward. This ward has 28 inpatient beds and will typically be operating at near capacity. In a sampling of 15 patients seen on a single day, 8 patients presented with seizures and headache due to Neurocysticercosis, 1 patient presented with loss of vision, seizure and headache due to a Tuberculosis granuloma, 1 patient presented with decreased consciousness and fever due to TB meningitis, 1 patient developed high grade fevers from presumed bacterial meningitis, 1 patient presented with headache and nausea/vomiting due to cryptococcal meningitis and diagnosed with AIDS, 1 patient with known HIV presented with seizure and diagnosed with presumed toxoplasmosis, 1 patient with headache and hemiparesis with likely glioblastoma multiforme and 1 patient with a multiple sclerosis flare with right arm and leg paresis (the unit cares for several noninfectious related diseases that are not vascular related). The average age of this small cohort was 40 years old.
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| A. Infectious disease ward at INCN. All patients are in one ward separated by men and women. B. Symptomatic patient with Racemose and intraparenchymal neurocysticercosis |
The use of the lumbar puncture is hindered at times as most Peruvians fear invasive testing and need coaxing into performing the procedure. At the INCN, most patients will have LP results but there is limited ability in obtaining gram stains, speciation, HSV PCR or other CSF diagnostic testing. Clinicians rely primarily on the cell count and differential, chloride, lactate, total protein and glucose along with the clinical story to make their diagnosis. They do not obtain opening pressure as they don't typically have manometers. In regards to imaging, the INCN does not have its own MRI at this time, but plans are currently ongoing. Of note, an MRI brain costs ~$250 (US dollars) which has to be paid for entirely by patients.
This past week, I also had the unexpected pleasure to visit Hospital Nacional Dos de Mayo in Lima (hdosdemayo.gob.pe) with a fabulous neurologist, Dr. Fred Raul Jeri. It is a hospital which serves adults and children and has most specialties including neurology. Dr. Jeri initially trained as a psychiatrist and then switched to neurology. He spent a year with the MGH neurology/neuropathology department, training under Dr. EP Richardson and Dr. Ray Adams. His project was to assist in the definition of neuropathological definition of irreversible coma with Dr. Richardson, work later published in 1968. A man in his 80s, he continues to see patients both as an inpatient neurology consultant and in his outpatient clinic, serving primarily HIV patients with neurological and psychiatric conditions. The neurology department has clinical neuropathology rounds every Wednesday morning with interesting cases including last week's case of a woman with HIV who developed progressive weakness of her legs. A chest xray revealed a cavitary lesion in the apex of her left lung which was eventually biopsied and ultimately diagnosed with thoracic actinomycosis which had spread to the vertebra resulting in cord compression.
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| One of the female general wards |
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| Outside Hospital Nacional Dos de Mayo |
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| Dr. Fred Raul Jeri in his clinic |
In this past week, I have learned an extraordinary amount about the clinical presentation of neurological infectious diseases, particularly the art of diagnosing and treating Neurocysticercosis, tuberculosis and HIV-related neurological disease in the setting of limited availability and not always rapid diagnostic testing. On my next blog, I will discuss some ongoing research in Neurocysticercosis.
I am grateful to the Partners Global Health Travel Grant, Partners Neurology Residency Program, Dr. Joseph Zunt and Dr. Hugo Garcia for coordinating and allowing me this amazing opportunity.
H7N9 cases in China to be reported weekly instead of daily.
Well that will let the guys at FluTrackers get some more sleep. Mike at Avian Flu Diary(who could probably do with some sleep too) notes it might not have a real impact on provincial reports but time will tell. The info is nestled at the bottom of this report.
This is a real shame for the public who have been getting access to some great real-time data break-downs, assemblies and interpretations from the flublogians.
Realistically, its not like we're entitled to these detailed data from China. It all takes work (and workers) to compile, release the number and organize and hold the official press conferences etc...but in the age of "always on" and instant internet gratification...I think we feel that is how it should be.
We would feel entitled to the information if it were a story about a terrorist act or the latest comings and goings of a public figure or personality, or sports scores. Its been nice to see something as important as the emergence of a new human pathogen receiving the attention it has...at least so far.
This is a real shame for the public who have been getting access to some great real-time data break-downs, assemblies and interpretations from the flublogians.
Realistically, its not like we're entitled to these detailed data from China. It all takes work (and workers) to compile, release the number and organize and hold the official press conferences etc...but in the age of "always on" and instant internet gratification...I think we feel that is how it should be.
We would feel entitled to the information if it were a story about a terrorist act or the latest comings and goings of a public figure or personality, or sports scores. Its been nice to see something as important as the emergence of a new human pathogen receiving the attention it has...at least so far.
Three hospital workers test negative.
Despite contact, and some confusion over whether they were or were not wearing personal protective equipment, they are H7N9 negative. So the upper respiratory tract infections (UTRIs; acute signs and symptoms including headache, perhaps a temperature, runny nose, sneezing, cough etc) they manifested after being in contact are due to another virus. Might be interesting to know which one(s).
Presumably Taiwan already screens for whatever it is as part of a standard "respiratory virus panel". Thanks to ClaireW for the link.
Shanghai looks for antibodies to H7N9 in healthy people!
..and I say WOO-HOO! This is an important step forward. Looking among the currently healthy for past exposure to H7N9 will tell us a lot.
These results will start to unravel how long this virus has been circulating in Shanghai (it takes a couple of weeks to "seroconvert"; show a jump in specific antibody levels in the blood; looking in any older paired sera repositories would be great too) and also how many cases, beyond the one child so far reported, of moderate, mild or asymptomatic infection there could have been.
These results will start to unravel how long this virus has been circulating in Shanghai (it takes a couple of weeks to "seroconvert"; show a jump in specific antibody levels in the blood; looking in any older paired sera repositories would be great too) and also how many cases, beyond the one child so far reported, of moderate, mild or asymptomatic infection there could have been.
Increasing that denominator is a great way to put the ability of H7N9 to cause severe illness in much clearer perspective.
Aaron Berkowitz
I spent one week in the capital city of Lilongwe at Malawi�s only medical school. It was the week of the preclinical students� neurology block. As the lone neurologist in the country, I was asked to participate by giving lectures on stroke, epilepsy, neuropathy, meningitis/encephalitis, HIV-related neurologic disorders, coma, headache, and interpretation of head CT (which is available in Lilongwe). I also assisted in the evaluation of students� clinical skills in an examination in which they performed neurologic examinations on patients and presented their findings.
Teaching at the medical school in Lilongwe
In teaching neurology here, I have realized that beyond participating in training non-neurologist physicians who will see a large burden of neurologic disease, a true achievement would be to inspire one (or several) students to train in neurology. I therefore emphasized in my lectures that 80% of the world�s 50 million epilepsy patients and nearly 90% of the world�s stroke deaths are in developing countries, and invited/challenged students to consider becoming the country�s first neurologist(s). The need is enormous- during this brief visit to the capital, I saw 10 patients with primary neurologic disease on the wards of Kamuzu Central Hospital, bringing my total number of consultations to over 40 in just a few short weeks.
One focus of the Partners in Health/Abwenzi Pa Za Umoyo outpatient chronic disease programs is epilepsy. As mentioned above, 80% percent of the world�s epilepsy burden is in the developing world, likely due to increased incidence of CNS infections, head trauma, and perinatal complications. It has been estimated that as many as 90% of patients may be untreated in some regions of the developing world, leading not only to unfortunate morbidity and mortality due to uncontrolled seizures but devastating stigma. Neno is fortunate to have a brilliant clinical officer, Grant Gonani, with training in mental health, who sees both psychiatric and neurologic patients. I spent one morning with him in his mental health clinic learning how he cares for his epilepsy patients and how epilepsy is managed here with the three available medications whose supplies may fluctuate. While in Neno, I also had the chance to give a presentation on seizures/epilepsy care to the clinical officers and nurses, and lead a practical session with the clinical officers on refining their neurologic examination skills.
The district hospital in Neno (left) and the outpatient clinic patient waiting area (right)
My time in Malawi has gone by all too fast, and I am very grateful to have had the chance to learn from diverse settings: the two largest hospitals in the two largest cities, the medical school, and a district health center in a more rural region. The need for neurology here is enormous, and I hope that I can continue to return to learn and teach. In the interim, I hope to continue collaborations and consultations by way of the internet.
I am very grateful to the administrators, medical students, clinical officers, residents, and attendings in Blantyre, Lilongwe, and Neno for so warmly welcoming me to Malawi and for allowing me to participate in the care of their patients and in their educational activities. I look forward to returning soon. I was also fortunate to work with an extraordinary mentor here, Dr. Gretchen Birbeck, one of the pioneers in global neurology. I also again want to thank the Partners Global Health Travel Grant and Partners Neurology Residency staff - Vanya Sagar and Silviya Eaton - and program leadership - Dr. Tracey Milligan, Dr. Tracey Cho, and Dr. Martin Samuels- for supporting this work.
PGY-3, Neurology
Travel Grant: Neurology Education in Malawi
After two weeks on the wards of Queen Elizabeth Central Hospital in Blantyre, described in my blog entry below, the last two weeks have taken me to two very different contexts in Malawi.
I spent one week in the capital city of Lilongwe at Malawi�s only medical school. It was the week of the preclinical students� neurology block. As the lone neurologist in the country, I was asked to participate by giving lectures on stroke, epilepsy, neuropathy, meningitis/encephalitis, HIV-related neurologic disorders, coma, headache, and interpretation of head CT (which is available in Lilongwe). I also assisted in the evaluation of students� clinical skills in an examination in which they performed neurologic examinations on patients and presented their findings.
Teaching at the medical school in Lilongwe
In teaching neurology here, I have realized that beyond participating in training non-neurologist physicians who will see a large burden of neurologic disease, a true achievement would be to inspire one (or several) students to train in neurology. I therefore emphasized in my lectures that 80% of the world�s 50 million epilepsy patients and nearly 90% of the world�s stroke deaths are in developing countries, and invited/challenged students to consider becoming the country�s first neurologist(s). The need is enormous- during this brief visit to the capital, I saw 10 patients with primary neurologic disease on the wards of Kamuzu Central Hospital, bringing my total number of consultations to over 40 in just a few short weeks.
The main entrance (left) and one ward (right) at Kamuzu Central Hospital in Lilongwe.?
This past week, I traveled to the district hospital of rural Neno, a stark contrast to the cities and the cities� large tertiary referral hospitals. It is here that Partners in Health/Abwenzi Pa Za Umoyo works with the Malawi Ministry of Health to support the district�s main hospital (about 80 beds) and a number of health centers in the region. One sharp turn off of one of the country�s main highways took us onto unpaved dirt roads shared with ox-drawn carriages.
The road to/through Neno (left) and one of the many villages in the district (right)
One focus of the Partners in Health/Abwenzi Pa Za Umoyo outpatient chronic disease programs is epilepsy. As mentioned above, 80% percent of the world�s epilepsy burden is in the developing world, likely due to increased incidence of CNS infections, head trauma, and perinatal complications. It has been estimated that as many as 90% of patients may be untreated in some regions of the developing world, leading not only to unfortunate morbidity and mortality due to uncontrolled seizures but devastating stigma. Neno is fortunate to have a brilliant clinical officer, Grant Gonani, with training in mental health, who sees both psychiatric and neurologic patients. I spent one morning with him in his mental health clinic learning how he cares for his epilepsy patients and how epilepsy is managed here with the three available medications whose supplies may fluctuate. While in Neno, I also had the chance to give a presentation on seizures/epilepsy care to the clinical officers and nurses, and lead a practical session with the clinical officers on refining their neurologic examination skills.
The district hospital in Neno (left) and the outpatient clinic patient waiting area (right)
My time in Malawi has gone by all too fast, and I am very grateful to have had the chance to learn from diverse settings: the two largest hospitals in the two largest cities, the medical school, and a district health center in a more rural region. The need for neurology here is enormous, and I hope that I can continue to return to learn and teach. In the interim, I hope to continue collaborations and consultations by way of the internet.
I am very grateful to the administrators, medical students, clinical officers, residents, and attendings in Blantyre, Lilongwe, and Neno for so warmly welcoming me to Malawi and for allowing me to participate in the care of their patients and in their educational activities. I look forward to returning soon. I was also fortunate to work with an extraordinary mentor here, Dr. Gretchen Birbeck, one of the pioneers in global neurology. I also again want to thank the Partners Global Health Travel Grant and Partners Neurology Residency staff - Vanya Sagar and Silviya Eaton - and program leadership - Dr. Tracey Milligan, Dr. Tracey Cho, and Dr. Martin Samuels- for supporting this work.
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Jiangxi tests positive for H7N9.
Given its proximity to Zhejiang its not too surprising that a case has been reported here-still to be confirmed by central testing.
However, I don't know of a provincial/municipal announcement that didn't get confirmed so the odds are good that a confirmation is forthcoming After a quiet yesterday, Zhejiang also has a couple more H7N9 cases to report.
Returning to the issue of H7N9 and its skewed presentations in the sexes.
I wrote about this on the 22.04.13 but forgot to mention that there are no accompanying descriptions of the societal roles of males and females in these areas, or in general.
The skewing may reflect a bias towards the males simply because they could be more involved in activities that increase their risk of exposure to the influenza A(H7N9) virus host or its environmental source.
A note on case fatality risk, rate or ratio (CFR)
..used in a couple of charts on the H7N9 page. This uses numbers based on very limited testing, publicly available data, recovered case numbers or understanding of the acquisition, transmission and clinical presentations associated with avian influenza A(H7N9) virus.
It is very early days yet however I think this number gives you an idea of our understanding at the moment. It will undoubtedly change in the coming days, weeks and years. To be pedantic, the CFR relies uses the number of discharges/recovered cases as the denominator for the CFR. However, that will sensationally inflate the result.
The CFR is often considered most useful at the end of an epidemic/pandemic, but less so when data-in-hand is limited such as during the early days of many outbreaks. Keeping in mind that some will take the CFR and multiply it by the world's population as an estimate of how many would die if the virus reached pandemic levels, I don't believe that approach is the best way to present the CFR metric for the emergence of a novel virus (usually first identified by the worst of the clinical presentations that will eventually be attributed to the virus).
You won't see that usage on VDU, you will see the "rolling" version though. The US CDC definition is useful here.
One of the most lethal influenza viruses.
Well of course that was going to be the quote picked up by the world's press from comments made by WHO Assistant-Director-General, Health Security and Environment, Dr Keiji Fukuda.
H7N9 is not the only game in town.
Three HCWs who looked after the first H7N9 exported case have developed upper respiratory tract(URTs) infections somewhere during the 15-days between illness onset and lab confirmation. It is well worth noting that H7N9 is not the only virus that can cause URTs.
There are over 200 endemic human "respiratory viruses" that have been associated with URTs including the rhinoviruses (160 of them alone), coronaviruses, adenoviruses, enteroviruses, parainfluenzaviruses, influenza viruses, metapneumovirus, respiratory syncytial virus and bocavirus. Working out what causes a patient's URT is a challenging task, especially when more than one of these viruses can be detected by PCR in a patients airway sample at the same time.
Differential diagnoses (testing for all the things that may cause the same clinical appearance) is interesting in times of an outbreak. Keep an eye on these HCWs - they could be an important canary in the dark H7N9 mine we've been stumbling about in so far.
There are over 200 endemic human "respiratory viruses" that have been associated with URTs including the rhinoviruses (160 of them alone), coronaviruses, adenoviruses, enteroviruses, parainfluenzaviruses, influenza viruses, metapneumovirus, respiratory syncytial virus and bocavirus. Working out what causes a patient's URT is a challenging task, especially when more than one of these viruses can be detected by PCR in a patients airway sample at the same time.
Differential diagnoses (testing for all the things that may cause the same clinical appearance) is interesting in times of an outbreak. Keep an eye on these HCWs - they could be an important canary in the dark H7N9 mine we've been stumbling about in so far.
H7N9 transported outside mainland China.
The first case of H7N9, has been reported reported in Taiwan marking its first known departure from the borders of mainland China. It seems that the 53-year old businessman imported it from somewhere on the mainland - he visited Suchou city in Jiangsu province, traveling out via Shanghai. He reportedly did not have any live birds or poultry.
There is now a risk of new cases emerging from close/regular/healthcare worker (HCW) contacts (n=138) he had (also also those during travel although he was pre-symptomatic and possibly not shedding), in the 3 three days he spent in Taiwan before showing signs of illness and at the medical facilities where he visited and was eventually admitted. If human-to-human transmission can happen, this will be the first chance to see it spread under the auspices of a different government. Four HCWs have cleared the suspected 7-day incubation period without symptoms while 3 HCWs have "developed" upper respiratory infections.
The patient did not seem to respond to Tamiflu but his infection was well advanced and beyond the recommended 48-hour commencement time (Tamiflu was started 16.04.13, about a week after first symptoms). His condition on 20.04.13 required intubation to manage respiratory failure.
The only upside to this "release" is that we may see and hear about some prospective testing which is sorely needed. Thanks to ClaireW and Jason Gale for the heads up.
There is now a risk of new cases emerging from close/regular/healthcare worker (HCW) contacts (n=138) he had (also also those during travel although he was pre-symptomatic and possibly not shedding), in the 3 three days he spent in Taiwan before showing signs of illness and at the medical facilities where he visited and was eventually admitted. If human-to-human transmission can happen, this will be the first chance to see it spread under the auspices of a different government. Four HCWs have cleared the suspected 7-day incubation period without symptoms while 3 HCWs have "developed" upper respiratory infections.
The patient did not seem to respond to Tamiflu but his infection was well advanced and beyond the recommended 48-hour commencement time (Tamiflu was started 16.04.13, about a week after first symptoms). His condition on 20.04.13 required intubation to manage respiratory failure.
The only upside to this "release" is that we may see and hear about some prospective testing which is sorely needed. Thanks to ClaireW and Jason Gale for the heads up.
Hepatitis B rears its tiny ugly head in the Taiwan case.
Apparently the 53M was also hepatitis B (HepB) positive as were 2/3 cases described in detail in the recent NEJM manuscript (see H7N9 page).
Is there an association between HepB virus/viral disease and H7N9 or are these co-detections just coincidence due to high prevalence of HepB infection in China (suggested here)?
Market closure the key?
Is the closure of Shanghai's wet animal markets to thank for the precipitous drop in H7N9 cases from Shanghai from around mid-April?
Back in 13.04.13 I mentioned we still had a few days to see if there was any impact based on the diagnostic testing lag of 10-12 days. Dr Kelso of the WHO influenza-A team thinks the drop and the market closures could be linked.
WHO panel wraps up visit.
"The primary focus of the investigation is to determine whether this is in fact spreading at a lower level among humans. But there is no evidence for that so far except in these very rare instances," said the WHO panel.
So presumably there are no signs or symptoms of disease spreading within these clusters. It is remains unclear from this visit whether the spread of the virus can be ruled out among these cases. Realistically (and pedantically), its very likely that the virus entered the airways and eyes of close contacts during sneezing, coughing etc. It just didn't cause obvious signs or self-reported symptoms of disease as a result of that challenge.
So presumably there are no signs or symptoms of disease spreading within these clusters. It is remains unclear from this visit whether the spread of the virus can be ruled out among these cases. Realistically (and pedantically), its very likely that the virus entered the airways and eyes of close contacts during sneezing, coughing etc. It just didn't cause obvious signs or self-reported symptoms of disease as a result of that challenge.
Presumably the virus lacks something when replicating in humans that it has when coming from the suspected animal source, which allows it to cause disease in humans. Or that other theory - it can infect humans and cause mild and subclinical disease.
The quickest way to resolve this question, a very important one for short-term and future containment of the virus, is to use PCR-based lab testing of contacts; look for virus in eye and upper airway swabs and, for a little bit, forget about being led by symptomatic illness alone.
The quickest way to resolve this question, a very important one for short-term and future containment of the virus, is to use PCR-based lab testing of contacts; look for virus in eye and upper airway swabs and, for a little bit, forget about being led by symptomatic illness alone.
Two deaths and 5 new confirmations tip the numbers above 100
..avian influenza A(H7N9) cases. Nothing has changed since yesterday, apart from Zhejiang province now surpassing Shanghai municipality in the total number of cases reported and accelerating (see chart below) in case numbers at a very rapid rate.
Still, but a 3-digit number tends to sound more scary to some - so expect the media to carry big banner headlines akin to "100 cases of killer virus in three weeks!"
Still, but a 3-digit number tends to sound more scary to some - so expect the media to carry big banner headlines akin to "100 cases of killer virus in three weeks!"
FluTrackers notes a new province has been added.
The H7N9 outbreak welcomes Shandong, about 870km north-west of Shanghai and 420km south of Beijing; population >95,000,000, of whom 1 (37M) is now confirmed as being H7N9-positive.
Given the rate of case reports from Zhejiang, I'm surprised we haven't heard from provinces further south such as Jiangxi or Fujian.
H7N9 and the tendency for males to predominate in case and fatality numbers.
The H7N9 graphs highlight that cases and deaths are occurring in males more than females. We often see more males than females in hospital presentations for acute respiratory illnesses. Why this is so is not known for certain.
Published research from Prof John Upham in Queensland, Australia shows a difference in the immune response to rhinovirus, the virus responsible for triggering most asthma attacks, between males and females in that females stronger response cleans up the virus, probably related to sex hormones.
Perhaps this can be extended to influenzavirus infections also.
Published research from Prof John Upham in Queensland, Australia shows a difference in the immune response to rhinovirus, the virus responsible for triggering most asthma attacks, between males and females in that females stronger response cleans up the virus, probably related to sex hormones.
This was supported by research from Dr Scotland in London, United Kingdom who found that female mice had more white blood cells and that these were more effective and less over-reactive than male cells in responding to invaders.
Perhaps this can be extended to influenzavirus infections also.
H7N9 and the skewed age issue.
We are reading much about the older than expected ages of those infected by H7N9 (current average case age of 58 years). Why? One school of thought is that the elderly have weaker, or perhaps "less experienced" immune defences.
But there are many other risk factors for severe complications arising after influenzavirus infection including heart and other organ disease, things which may accumulate with age.
This shift is not uncommon among pandemic influenzaviruses - those settling in to a new host. Also worth noting: (1) seasonal influenza is commonly regarded as having its worst impact in those over 65 years of age, (2) influenza A(H5N1) virus (the other bird flu) has had its biggest impact in pre-adults and young adults (15-39)(3) the influenza A(H1N1)pdm virus (swine flu) had its greatest impact on children and young adults and(4) influenza A(H7N7) virus was confirmed in 89 people (average age 30 years among mostly workers culling chickens), mostly mild, including conjunctivitis.
That' a lot of diversity. Begs the question of whether we can predict too much about H7N9 until we've lived with it a bit longer.
This shift is not uncommon among pandemic influenzaviruses - those settling in to a new host. Also worth noting: (1) seasonal influenza is commonly regarded as having its worst impact in those over 65 years of age, (2) influenza A(H5N1) virus (the other bird flu) has had its biggest impact in pre-adults and young adults (15-39)(3) the influenza A(H1N1)pdm virus (swine flu) had its greatest impact on children and young adults and(4) influenza A(H7N7) virus was confirmed in 89 people (average age 30 years among mostly workers culling chickens), mostly mild, including conjunctivitis.
That' a lot of diversity. Begs the question of whether we can predict too much about H7N9 until we've lived with it a bit longer.
Absence of evidence is not evidence of absence. Welcome to the end of the third week.
Three weeks since the WHO was notified of the newly emerged avian influenza A(H7N9) virus.
Today the case tally sits at 97 confirmation including 18 deaths, an asymptomatic case, three family clusters, no proven or sustained human-to-human transmission, no clear host in poultry or wild birds or pigs (all things that history or H7N9 genetic sequences indicate should be hosting infection).
Today the case tally sits at 97 confirmation including 18 deaths, an asymptomatic case, three family clusters, no proven or sustained human-to-human transmission, no clear host in poultry or wild birds or pigs (all things that history or H7N9 genetic sequences indicate should be hosting infection).
