1. Avian Influenza H7N9 Situation Analysis and Prevention Dr. Tong Ka Io 2013.04.18

3. Spatial distribution Shanghai municipality Zhejiang province: Hangzhou, Huzhou, Jiaxing Anhui province: Xuzhou, Haozhou Jiangsu province: Nanjing, Suqian, Suzhou, Wuxi, Rugao, Zhenjiang, Yaozhou, Changshou, Jiangying, Yancheng, Kunshan Henan province: Kaifeng, Zhoukou, Zhengzhou Beijing municipality

4. Spatial distribution

5. Shanghai 02.19~ 32 cases 11 deaths Zhejiang 03.07~ 27 cases 2 deaths Anhui 03.09~ 3 cases 1 death Jiangsu 03.19~ 21 cases 3 deaths Henan 04.06~ 3 cases 0 death Beijing 04.11~ 1 case 0 death

6. Interpersonal distribution Of the first 87 cases ŸAge range = 2~87y, median = 63y, elder people more common, only 3 child cases with milder clinical presentations M:F = 2.4:1 Occupational exposure to birds in at least 19 cases, retired people account for 44 cases, none HCW It was said that most fatal cases were male smokers

8. Suspect clusters 1) Shanghai Li’s family 55y son became ill on 11 th Feb, with severe pneumonia, died on 28 th Feb, no sample collected for H7N9 testing 87y father became ill on 19 th Feb, with severe pneumonia, died on 4 th Mar, H7N9 PCR positive 69y son became ill on 19 th Feb, with milder clinical course, H7N9 PCR negative, retrospective serological test positive

9. Suspect clusters 2) Jiangsu Zhang’s family 32y daughter became ill on 21 st Mar, H7N9 PCR positive Her father had been ill before, H7N9 tests negative

10. Suspect clusters 3) Shanghai Gu’s family 52y wife became ill on 27 th Mar, died on 3 rd Apr, H7N9 PCR positive 56y husband became ill on 1 st Apr, H7N9 PCR positive

12. Hypothetical mixing of avian flu viruses from east Asia migratory birds and east China ducks and chickens.

13. Animal and environment testing Since 20 th Mar, animal facilities around human cases in Anhui, Jiangsu and Shanghai had been checked, with no animal illness found. Until 3 rd Apr, agricultural departments of Shanghai, Jiangsu, Zhejiang, and Anhui did not have specific testing agents for H7N9.

14. Animal and environment testing As of 16 th Apr, provincial and national AI reference laboratories had collected a total of 84444 samples, covering 473 live poultry markets, 32 slaughterhouses, 896 farms, 79 wild bird habitats, 36 pig slaughterhouses, and 137 environmental sampling spots. Tests for 47801 samples had been concluded, yielding only 39 positive results (0.05%), of which 38 were poultry and environment samples from live markets of Shanghai, Anhui, Zhejiang and Jiangsu, 1 was from wild pigeon from Nanjing, Jiangsu.

15. Positive tests DateSampling sitesPositive ratePositive samples 04.04Shanghai Huhuai Market?/?Shanghai Huhuai MarketPigeon 04.05Shanghai live markets19/738(2.6%) Huhuai MarketChicken, environment Jingchuan MarketChicken, environment Fengzhuang Market Chicken, pigeon, environment 04.06 Zhejiang Hangzhou Bangsheng Market 5/12(41.7%) Zhejiang Hangzhou Bangsheng Market Environment 04.10 Farms and live markets in Jiangsu, Zhejiang and Anhui province 14/2099(0.7%) Zhejiang Huzhou Zhebei MarketDuck Anhui Hefei Huishangcheng Market Duck 3 markets in JiangsuChicken 04.16 Suspect samples from Jiangsu and Zhejiang 5/12/? Jiangsu NanjingWild pigeon Zhejiang Huzhou Zhebei MarketChicken Zhejiang Huzhou Daoxiang MarketChicken

16. Negative tests DateLocationSamplequantityTests 04.02Shanghai natural preservation district and zoos Migratory and wild birds229H7 gene ~04.09Shanghai farmsAnimals366AI common PCR 04.01~04.11Farms, parks, wild bird habitats and supermarkets in 16 districts of Beijing Chickens, pigs, ducks, gooses, pigeons, crows, wild birds, animal products 5609? 04.14Gucheng villange in BeijingPoultry61+ 95 Virology+ Serology End of Mar ~04.17 35 pig farms and 11 pig slaughterhouses in Shanghai, Anhui, Zhejiang, and Jiangsu Pigs2050+ 2000 Virology+ Serology

17. Source of H7N9 virus may be the migratory birds in Changjiang river mouth Ducks along the bank of Changjiang river may be all infected

19. H7N9 continuously evolves, hard to predict risk The virus is still searching for a more compatible combination

20. Risk assessment 1. The reassortment of avian influenza viruses had occurred, probably in East China 2. The reassorted virus massively go across the animal-human boundary to infect human 3. The virus is low pathogenic for birds and highly pathogenic for human 4. Up to the moment, there is no evidence that the virus further go across the boundary to sustained human- to-human transmission, though limited human-to- human transmission can not be excluded

21. Avian influenza dynamics

22. Phase 1 Bird-to-bird transmission Phase 2 Bird-to-human transmission & limited human-to-human transmission Phase 3 Widespread human-to-human transmission Avian disease surveillance, prevention and control Minimizing human exposure Detection and isolation of human cases Ensuring care for patients Slowing down spread H1~H16 H7N9

23. Risk assessment 5. It is probably that the virus spreads beyond East China to Central and North China by migratory birds, which infect local Poultry and the latter infect human 6. Comparing with H5N1, H7N9 infection in poultry seems more widespread and persistent, constituting a greater threat for human 7. At this moment, it is impossible to precisely predict if the virus will come to Macao, or how (birds or human?), but preparedness is necessary

24. Animal-animal line of defense Separate poultry with migratory birds and wild birds Separate water fowls and land fowls Separate poultry from different regions Separate infected poultry with other poultry

25. Significant measures taken in Macao  All local poultry farms eliminated  Raising poultry prohibited  Importation of live water fowls prohibited  Management in the source, surveillance, separation, and double quarantine for poultry provided from inland to Macao  Culling of all live poultry before the live markets close everyday

26. Animal-human line of defense Biosafety measures for poultry industry. In case of animal epidemic, handling infected poultry under strict protection General people avoiding contact with live poultry or presenting in places with live poultry, washing hands after contact with raw poultry meat or egg, eating poultry meat or eggs thoroughly cooked According to situational, government adopting appropriate risk management measures in sites for poultry wholesale, sale, or watching

27. Human-human line of defense Raising people’s alert for prompt seeking medical advice if severe acute respiratory illness develops Raising HCW alert, strengthening surveillance system, building laboratory capacity, testing acute respiratory patients with travel, poultry or patient contact history, and patients with pneumonia of unknown cause, for early detection of cases Strengthening infection control in medical facilities. Early isolation and treatment of detected cases Tracing and health management of close contacts of cases