20130506 H7N9 and the flow of information

H7N9 and the flow of information

By Liu Ching-ming 劉競明

Taiwan’s first reported case of H7N9 avian influenza was a Taiwanese businessman who had traveled to the Kunshan area of Suzhou in China’s Jiangsu Province.

During his visit, he played a round of golf and had no direct contact with birds or poultry of any kind. On returning to Taiwan on April 9, he had no fever and showed no symptoms of influenza.

However, three days later, symptoms began to appear and they became increasingly severe. The man’s condition deteriorated so severely that he had to be put on extracorporeal membrane oxygenation (ECMO) to save his life.

Recently, the Centers for Disease Control suggested that he may have been infected by coming into contact with bird droppings or other infected matter when picking up golf balls during his round of golf. However, one problem is that nobody knows whether he had been given flu vaccines in the past or whether he had been in contact with large groups of people.

It is also not known whether, apart from having high blood pressure and being a hepatitis B carrier, he has had influenza in the past. Perhaps he put off getting treatment for influenza for too long, so that the condition got progressively worse, otherwise he would have antibodies to the virus in his body, in which case he would not have ended up in such a serious state.

Based on reports of the 100 or so cases of H7N9 infection that have been reported in China, middle-aged and elderly men are more prone to dying from the virus. In addition, this strain of avian influenza specifically attacks the lower respiratory tract and this causes problems with the lungs and heart, resulting in pulmonary edema and breathing difficulties. In the later stages of infection, H7N9 patients are often sent to intensive care units with respiratory failure.

The upper respiratory tracts of middle-aged and elderly men have multiple pathogenic antigens that have built up over the years, and if these men are infected with the H7N9 virus, even if they just come into contact with small amounts of dried and powdered bird droppings flowing through the air, the cilia in their trachea will allow the H7N9 virus to go straight into the lungs, because of chronic illnesses such as bronchitis, obstructive pulmonary emphysema, asthma allergies and chronic inflammation.

Once in the lungs, the virus can become hidden and will gradually become increasingly severe. If Tamiflu is not administered to a patient early enough, once the virus gets stronger than their immune system can cope with, ECMO will become necessary because the patient may develop idiopathic pulmonary fibrosis and respiratory failure.

This echoes comments made by Ho Mei-shang (何美鄉), a research fellow at Academia Sinica’s Institute of Biomedical Sciences, who said that this virus goes straight to the lungs and that middle-aged and elderly are at greater risk from the disease.

As a doctor, I have personally taken part in healthcare administration accreditation and the training of teachers. On one occasion, somebody commented that if Taiwanese hospitals are to be accredited by the Joint Commission International — an organization that promotes standards of care by working together with healthcare organizations and governments — the most important task is to improve sanitary levels and hospital flow.

This means that the biggest problem with Taiwan’s hospitals is that they are dirty and disorganized.

However, it does not stop there — we should also add viruses to the list.

And what about China? The thousands of dead pigs that were recently discovered floating down the Huangpu River in Shanghai and the heavy air pollution blanketing Beijing a few months ago show that cleanliness and public health in many Chinese cities have been almost completely neglected. The H7N9 outbreak that China is experiencing reflects the fact that many cities in China and the sanitary habits of their inhabitants are also “dirty and disorganized.”

China’s “Golden Week,” a semi-annual seven-day national holiday, has started and at this time there are two vital questions we should be asking.

First, we should ask whether cases of H7N9 infection will reach a new peak as contact between people from China and Taiwan increases and second, whether our health authorities can work harder to get Chinese health authorities to be more transparent with information obtained via their research on H7N9 and let the public know exactly what is going on.

Liu Ching-ming is an attending physician and assistant professor in the department of obstetrics and gynecology at Linkou Chang Gung Memorial Hospital.

Translated by Drew Cameron