What is the difference between avian flu and ordinary flu?
After the Lunar New Year, flu cases surged rapidly. Last week severe cases jumped by 338, hitting a 5-year high. Emergency rooms at hospitals everywhere are packed beyond capacity, intensive care unit staffing and equipment are severely inadequate, and hospitals are scrambling for ECMO machines, raising fears that this could become the most severe respiratory infectious disease outbreak since SARS.
Meanwhile, on February 24, Hong Kong, China reported its first human case of H7N9 avian flu this year; the patient is a 60-year-old man who has long worked in Suzhou, China. Since China first reported human H7N9 cases in 2013, as of January 20 this year, there have been 693 confirmed cases worldwide, with 277 deaths and a mortality rate as high as 40 percent, and still no vaccine. Although Taiwan has not yet reported any local cases, there have already been 2 imported cases from China.
The symptoms of H7N9 resemble those of ordinary seasonal flu, and with frequent cross-strait travel during the Lunar New Year holiday, has the virus been brought into Taiwan? Could some people in this flu wave actually be infected with H7N9 without knowing it? This deserves close attention.
Jin Chuan-chun, a professor at National Taiwan University's College of Public Health, Institute of Epidemiology and Preventive Medicine, who participated in SARS prevention and control and in recent years has devoted herself to avian flu research, gave a special interview to News&Market. She urged the public, medical personnel and laboratory technicians to raise their vigilance and be sure to report any history of contact with poultry or pigs and any travel history to epidemic areas.
News&Market will publish the interview with Jin Chuan-chun in two parts; this article is the first in the series.
Q: After the Lunar New Year, Taiwan's flu situation has surged and hospitals are overcrowded. How should one distinguish the symptoms of ordinary flu from avian flu? If a human case of avian flu is found, what measures should be taken to prevent hospital-acquired infection?
You cannot tell just by looking at clinical symptoms, because the symptoms of avian flu infection are very similar to those of ordinary human flu (some Hong Kong studies have found gastrointestinal symptoms in human cases of avian flu infection). Still, it is essential to combine this with epidemiology and ask about the patient's contact history, travel history, whether they have participated in slaughtering, had contact with poultry, or been responsible for preparing poultry-related dishes at home, and so on. Sometimes it is not direct contact but indirect contact, so besides asking where the patient and their family or friends have been, you also need to ask whether they have had contact with poultry, pigs, or this kind of patient.
Recently emergency rooms have been overflowing, ICU medical staff are stretched thin, and ECMO machines are also insufficient. Although doctors should ask about TOCC when diagnosing (Travel history, Occupation, such as livestock farming, veterinary medicine, live poultry market workers, restaurant kitchen staff handling animal meat/eggs, etc., Contact history, Cluster), right now the emergency rooms are so crowded that doctors have no time to ask, the health bureau has not asked either, and patients have not proactively reported it. If we keep thinking the virus comes only from outside, just as when SARS began spreading within Taiwan, we will miss cases without realizing it, and the virus can easily seize the opportunity to grow stronger!
Another key point is that poultry farmers or slaughter and epidemic prevention workers, once they have respiratory symptoms, must wear masks when seeking medical care, must never touch their mouth or nose with their hands, to reduce risk, and should tell medical staff that they are poultry or livestock workers, and ask medical personnel to collect specimens under safe protection. Earlier, Taiwan's Centers for Disease Control caught the world's first case of H6N1 infecting a human precisely because our surveillance was strong enough and we went to collect specimens. If we wait until we see a bunch of human-to-human transmissions, by then the virus will already have adapted to the human population.
Avian flu viruses may be able to infect humans after just a few amino acid changes. Former Taipei City Health Bureau disease control division chief Yen Mu-yung, when the 2009 novel influenza human cases were spreading in other countries, had already established a good detection system, making it convenient for poultry and livestock workers to seek medical care early, proactively tell medical staff their identity, and immediately receive the best medical care, benefiting themselves and protecting others.
Tamiflu is still effective against some avian flu viruses. If discovered early and used early, it also provides an immediate effectiveness assessment of Tamiflu in this high-risk group, and whether it can continue to serve as an epidemic prevention weapon.
In addition, education for Taiwanese businesspeople is also very important. Some infected Taiwanese businesspeople return to Taiwan, but we cannot grasp where they have been. When H5N1 first began spreading and infecting humans, then-President Chen Shui-bian, at a Lunar New Year fifth-day gathering, gave me half an hour to talk to Taiwanese businesspeople going to China about avian flu. I also once gave lectures to personnel of Taiwanese companies with branches on the mainland, but later it was no longer done, showing that people now have low sensitivity to avian flu, only getting to know it from the news after the epidemic worsens, but still not understanding the characteristics of this virus and its epidemiology, so epidemic prevention will achieve half the result with twice the effort.
On the other hand, many H7N9 cases in Taiwan so far have been to Jiangsu, so it is necessary for us to understand the epidemiological characteristics of H7N9 in Jiangsu. The two sides of the Taiwan Strait can exchange information and cooperate frankly in epidemiology.
Asia is the base camp of avian flu viruses; Taiwan has an international social responsibility
At the same time, Jin Chuan-chun also worries that the government, facing Taiwan's largest wave ever of H5 avian flu virus since last year, did not quickly establish a cross-disciplinary and cross-university scientific research team as it did during the 2003 SARS outbreak, losing the opportunity to cultivate young talent in avian flu scientific research and problem-solving.
Drawing on the SARS experience, she reminds the government that it should establish an Executive Yuan-level platform involving cross-disciplinary talent such as veterinarians, wild bird specialists, ecologists, virologists, infectious disease surveillance experts, bioinformatics specialists, epidemiologists, statisticians, economists and risk communication experts, and cooperate with China, Hong Kong, China, Japan, South Korea, Thailand and Australia in avian flu virus surveillance. Especially since next month is the season for migratory birds to fly north, and Asia is the world's largest hotbed of avian flu viruses, "Taiwan has a global responsibility and must never allow a new virus to emerge from Taiwan and continue to spread."
Q: In recent years the world has faced many disease threats, including the recent Zika virus, dengue fever and avian flu. Viruses spread rapidly with global population movement. In this era of increasingly convenient transportation, what does the professor think Taiwan's mission and role are in global epidemiology?
The avian flu outbreak in Taiwan last year was the largest wave in our history, with four viruses in total, including the three subtypes H5N8, H5N2 and H5N3 appearing in Taiwan for the first time, as well as the old H5N2 virus that originally circulated in chickens. Waterfowl deaths were severe, unlike in the past when mostly land poultry were hit.
Moreover, the avian flu viruses circulating in Taiwan are different from those in other countries. Most other countries only have the two subtypes H5N2 and H5N8, while we also have the H5N3 subtype. More importantly, Taiwan has seen two different subtypes of avian flu virus appear on the same poultry farm. Coupled with close exchanges between Taiwan and mainland China, some provinces in China already have human avian flu cases, and there are two different avian flu viruses, with human cases of two different avian flu viruses appearing in the same province, so epidemic prevention vigilance must absolutely be raised.
Asia is an important birthplace of novel influenza viruses. The global flu that broke out in 1957 was called Asian flu, and 1968 was Hong Kong flu. As Asian viruses become more complex, Taiwan has had a foot in it every time. When the new H7N9 broke out we were affected, and with last year's H5 avian flu wave in Taiwan, as well as Taiwan's world-first human case of H6N1, we have a responsibility to protect Taiwan well and also shoulder the heavy responsibility for global animal health and public health.