Transcript of media briefing by Dr Michael O'Leary, WHO Representative in China

Situation update on H7N9 in China

Beijing, China
19 April 2013

DR MICHAEL O’LEARY: Good afternoon, and thank you for coming. I want to take this opportunity today to give you another update on the situation with avian influenza A(H7N9), to tell you a little about the WHO joint mission to China, , and to answer a few questions.

First, about the mission. This week, WHO and the China National Health and Family Planning Commission are leading a joint mission of experts, at the invitation of the Government of China. The experts will visit areas affected by H7N9 in order to study the situation and provide recommendations on prevention and control of the disease.

I will be accompanying the team which will be visiting a number of sites in both Shanghai and Beijing.

Our team includes international and Chinese experts in epidemiology, laboratories, clinical management, and other areas. We will be meeting with a wide range of experts.

The mission is just getting underway so there are not yet findings to report. At the end, on return to Beijing early next week, the team will discuss its findings and make initial recommendations. China's National Health and Family Planning Commission has said it will release findings from the mission at a later time.

I want to emphasize the greater significance of the team's presence. It is a concrete example of international cooperation in action. It is also a demonstration of China's openness in investigating this situation. I want to note that this is not because of changes in the scope or scale of the event – there continue to be sporadic cases reported every day but our risk assessment has not changed – nor is it because of concerns about the investigation itself, as Chinese authorities have been demonstrating their capacity for this investigation. As you know, information is being released quickly, and through various channels. We remain pleased with this transparency and with our collaboration.

Instead, this mission is an opportunity for international influenza experts to learn from people at the front lines of their findings on this new virus. It also gives Chinese local experts the chance to direct their questions to world experts. The public health world is one with few boundaries, as diseases can emerge in any country, and do not respect national borders. The international community of influenza experts, in which China is an important player, exemplifies this "one-world" view.

Now, what will we be looking for and discussing? We have some of the same questions as I know you do.

For example, the source of the virus. Evidence suggests that poultry is a vehicle of transmission. But epidemiologists haven't yet been able to establish a strong and clear link. However in any case this would not be from eating properly cooked poultry, which is considered fully safe for consumption.

From the animal side, only a handful of the tens of thousands of chicken and birds tested have been positive for H7N9, no positive in pigs, also virtually none of those animals, were sick, in contrast to H5N1, which is the bird flu we are more familiar with, and which has been with us for more than 15 years. With this different situation in animals, the presumed source of infection, we are still uncertain about the source of illness in people.

We know that, with perhaps rare exceptions, people are not getting sick from other people. Of the many hundreds of people who were in close contact with the H7N9 patients, all the care-givers, neighbors, family members, and so on, there are only a very few cases where these contacts have become ill as well. These are the little clusters of illness authorities are paying special attention to.

This week we had one confirmation, in the very sad case of the father and his two sons who were also ill (where) the father and the younger son died. Authorities say blood tests show that both the father and the older son had H7N9. That son has now recovered from pneumonia.

This might be a case of one person passing the disease to another, or they may have all been exposed to the same source of infection. We cannot say for certain. I want to clarify though that even though we are concerned if the disease can pass from one person to another, it still seems that this does not happen easily, or we would see many such cases. We have not seen easy and sustained person-to-person transmission. This is the situation for which we are most vigilant.

These are some of the questions the team will be focusing on over the next few days. We are curious, you are curious, and we relish this opportunity to work closely with the people who have been on the frontlines of the response.

Our job, once we have gained this deeper knowledge, is to continue to inform the scientific community, to inform the public of important issues, to inform other countries who are following this closely, and to enrich our analysis of the risks we may be facing.

Arrangements are not finalized but we aim to be available to speak with the media again at least once before the end of the mission.

I would be remiss if I did not mention our public health advice, which remains that people should cook poultry till it is well done, to an internal temperature of 70 degrees Celsius with no pink parts, separate and clean before reusing any cooking equipment that has been in contact with raw meats, regular hand-washing, and infection control measures to protect yourself if you are caring for a sick relative or if you are a healthcare worker.

I can take a few of your questions now.

JOURNALIST: (I’m) From the Associated Press. Could you give us a few more details of which experts are in this team, what areas they are focusing on? Especially where they actually come from? And also on the few cases of person-to-person transmission besides the Shanghai family clusters, which other cases have raise some concerns?

JOURNALIST: And how many experts are there?

DR MICHAEL O’LEARY: OK, good. So about the expert team, first of all, the team as a whole constitutes about 15 people. 5 or so of those are from the Chinese government, from our colleagues at China CDC, and the ministries. Four are WHO experts, there will be 2 of us from the country office here, we also have 1 from our regional office in Manila and 2 from our headquarters in Geneva. So that’s 5 WHO staff members will accompany the group. The ones from Geneva and from Manila are some of our top experts in the subject area, and the international expert team that's coming consists of people from four countries. From the US, from the [US Centers for Disease Control and Prevention]. There’s a collaborating centre on influenza, also a collaborating centre in Melbourne, Australia. In influenza as well with the mission, we have an expert from Hong Kong, who additionally has considerable experience in the animal side of virology, and an epidemiologist and expert from the [European Centre for Prevention and Control]. So the international expert team, besides WHO staff, are from Europe, from US, from Australia and from Hong Kong.

About the clusters, was the second question. There are 3 clusters officially reported, I mentioned one of them, the one with the father and 2 sons… 2 of whom, the father and the son who did not die, were confirmed H7N9. So that’s one of the clusters, and we know about another cluster of a parent and a child, where the daughter was caring for the parent who was very sick, and became sick herself with the H7N9. A third cluster as well, a husband-and-wife cluster. In both of those, people were sick with severe pneumonia, and so were linked clinically. But I think it’s still the case that in both of those, only one of them is so far confirmed, but the investigations are continuing. And then we know about the other are still under active investigation, the more recent situation here in Beijing, the 7-year-girl who is now released from the hospital, an asymptomatic, [meaning he had] no symptoms, neighbor. Laboratory investigation is still underway, but he is suspected as being positive as well. But that child was not ill.

JOURNALIST: I am just wondering that, in addition to Beijing and Shanghai, will the team of experts also be travelling to Jiangsu and other affected areas?

DR MICHAEL O’LEARY: We’ll be travelling in the perimeter outside Shanghai, but we are not going more than an hour away as I understand. The ministry set a schedule for us. There’s only a few days in fact, so we’ll be concentrating on that area.

JOURNALIST: Despite the advice you are giving, what do you expect the public reaction to be?

DR MICHAEL O’LEARY: We know that from the [past], we had many outbreaks related to poultry. Sometimes there can be an overreaction, concern about poultry, for example, eating poultry. We still don’t know for sure, as I have mentioned, the source of infection here, but this remains our strongest line of investigation, because, first of all, this is an avian-related virus, and also many---many, but not all---of the cases, we have been able to demonstrate a link to poultry. So that’s one reaction that we might see [concern about eating poultry], but we hope to calm the issue about eating poultry because that’s never been an issue as long as the poultry is properly prepared and cooked. So at this point, this is a little bit unusual that we haven’t been finding sick poultry effectively. The test had been done as part of the investigation, there’s been more than 80,000 birds [sampled, and 47,000] tested so far, fewer than 40 positive, and they were not sick. So that’s unlike some previous investigations where, you know, this was a serious infection among the poultry population as well.

JOURNALIST: I’m from China Radio International. Two questions. One, on Tuesday, Hong Kong Health Organization said that this might be a limited human-to-human transmission; do you have any comments on this? And the second question, it was reported before that this team will go to the bird market in Shanghai, where else are they going? Like labs or hospital?

DR MICHAEL O’LEARY: Yes, sure. About limited person-to-person transmission, I mentioned that these clusters are under investigations. It’s not unusual even when a virus primarily is transmitting from animal-to-human, to have some rare or occasional cases, of very close contacts, coming down with the virus as well. That’s happened in H5N1 for example. But that’s a very different situation from easy and sustained transmission. And that’s what we do not see in this case. It’s not unexpected that if a person is sick and may be receiving very close care, from a very close contact, that once in a while, it will pass to the other person, but this is not the same as sustained human-to-human transmission. So, that’s what we are very alert for, because this becomes a different situation if the virus were to change in a way that enabled human-to-human transmission. Still, that’s not the case, we hope that will never be the case. But that’s what we watch for. Other question about where was the team visiting. Yes, bird markets, although as you know, the live bird markets in Shanghai have been closed. So there won’t be a lot to see. But the team is also on schedule to visit hospitals and other sites that have been the focus of the infection.

JOURNALIST: From BBC News. Could you please just tell me, to be clear, what do you think the risks are in this outbreak? How serious do you think it is? You mentioned the concern about human-to-human, but what is the biggest concern to you?

DR MICHAEL O’LEARY: So, you know if the virus remains a primarily animal virus, then the risks to humans, would be expected, I think, to remain rare and sporadic, just as they have been. You know, this is a different virus from H5N1. It may ultimately act differently, but for H5N1 [this] has been the case for 16 years and is still just the occasional, sporadic case, because it’s effectively an animal virus that once in a while, manages to jump to a human. So the situation changes, as I say, if the virus changes in a way that human-to-human transmission is possible, that’s a separate change from the one that has taken place already. You know, we can’t predict, there’s no way to predict, but it would really require now a separate mutation from the one we’ve seen, because there isn’t any evidence of that happening so far.

JOURNALIST: Do you recommend the authorities to begin culling poultry? And reason.

DR MICHAEL O’LEARY: There has been some culling done, as you probably know. It has been, and is, one of the potential measures for controlling the sporadic virus in chickens, the interesting thing so far here, is that so few tests have come up positive in chickens, plus those chickens are healthy. So it’s a more difficult question I would say about, whether and when to cull, because it certainly has significant economic impact as well, and I think that’s already been felt in some places. Should the virus be transmitted easily in chickens, that’s definitely one of the measures that can be undertaken.

JOURNALIST: Does it make sense to do it now?

DR MICHAEL O’LEARY: I think in most situations it’s premature to do that now. If it were found in a particular population of chickens, to be spreading and to be a risk, that would be the place that might happen, there has been some culling which was appropriate to control, to contain, in a particular area, so I wouldn’t say that the culling that’s been done or so was all incorrect, but it (unintelligible) is to do widespread culling until we know more about the chicken population. We are waiting to see what the situation really is.

JOURNALIST: AFP. You said there’s been rare examples about whether maybe the evidence of contact between humans just exposed to it… just read several reports recently saying that about half of those infected haven’t had contacts with chicken. Are they true? And how people have been infected if there is only a small minority that have contacted with patients.

DR MICHAEL O’LEARY: As the investigation gets deeper, we have found more, I think it’s now more than half, where there’s known contact with poultry. The investigation is often difficult to determine all the exposures that the person might have particularly when they are thinking back a bit in time and so on. So, in any investigation we don’t really have full knowledge of information about contact. So that’s what makes it a bit more difficult right now to definitively rule in or certainly to (unintelligible) chickens, and I think that we would still be waiting for deeper information.

JOURNALIST: As we know from other events of viruses, the virus is able to transform quickly. Have you any indications that H7N9 has already been transforming and do we expect this now?

DR MICHAEL O’LEARY: Now we are only three weeks into the discovery of this virus, and an amazing amount actually is happening in those three weeks, and so much is learned about this virus already. It’s been genetically mapped quite quickly, and the virologists who do this work and laboratory people who do this work, have been able to determine the kind of reassortment that took place to create this virus in the beginning, where is the source virus that it is related to. Continuing reassortments always take place in influenza virus, that’s one of the features of influenza. It’s why we need a different influenza vaccine every year, because it’s always changing. But there haven’t been any major adjustments in these three weeks, and it’s of course unpredictable about where we’ll go.

JOURNALIST: About the two family clusters in Shanghai, do they really involve human-to-human transmission, or still under investigation?

DR MICHAEL O’LEARY: It’s still under investigation. But it’s always very difficult to definitively say because when there are two people in the same family, even if they have confirmation that they are both infected with the same virus, it’s extremely difficult or impossible to sort out whether one gave it to the other, or they both got it from the same source. And that’s actually the issue. There’s no real way to tell that in the end, definitively. So unless we can definitively prove the source, we can’t really say. These clusters are of concern, obviously, for investigation, because of the possibility that represents human-to-human transmission. But as I mentioned before, this is the very limited, rare sort of human-to-human transmission, rather than easy and sustained transmission that would suggest that this could be the sort of virus that emerges into a human pandemic virus. Right now it’s still an animal virus that occasionally infects humans.

JOURNALIST: From HK’s TVB. Several questions. You mentioned earlier that this trip demonstrates China’s openness, but then you also said that your visit to Shanghai is somewhat limited and arranged by the ministry. Are there any sites that you requested to visit but you’ve been rejected? And would you be able to expose the name of that Hong Kong expert?

DR MICHAEL O’LEARY: No, sorry, the National Health and Family Planning Commission, they know the situation, they are on top of details, the team is satisfied with the itinerary, and I know it’s already dialogued in terms of where we go. So that’s not an issue. I think they were, we feel, perfectly open to explore any areas. I did say that this demonstrates, in our view, the openness of the government. This is very quick to invite in an international team. It’s because the interest is strong internationally and strong in China. And we all want to figure out what the problem is. So, we’re really working together on that.

JOURNALIST: How can I know the name of the Hong Kong expert?

DR MICHAEL O’LEARY: I thought the names were released already now. [Journalist: is it Malik Peiris?] It’s Malik Peiris. The team members are also from the US CDC, from Melbourne lab and from [European Centre for Disease Prevention and Control].

JOURNALIST: Assuming you’re not a vegetarian, when was the last time you ordered chicken in China?

DR MICHAEL O’LEARY: Oh I don’t hesitate to do that, I eat chicken every day, or almost every day, and I don’t change that at all. Eating chicken is of no concern to me.

JOURNALIST: Among these clusters you mentioned, how many confirmed cases of H7N9?

DR MICHAEL O’LEARY: The most definitive one is the cluster three that I specifically mentioned where the father and the younger son. The father was 87 and the son was in his 60s. The father and the younger son both died. And the father and the older son who survived, both were confirmed. The younger son died before the testing was available, one of the first cases. So, there are two confirmed cases in that cluster. The others are still under investigations. So it can’t be said definitively.

JOURNALIST: I’m from Japanese TV station. How do you evaluate the death rate of this bird flu?

DR MICHAEL O’LEARY: So, one of the unknown issues still, that is the primary purpose of the investigation, is to determine the serious cases that are occurring. We know the number of cases and now I think the current total is 87 cases and 17 deaths. You’ll have that information as well. I mean, that’s fairly high mortality rate, particularly because several others are in critical condition. But what we don’t know is the size of the iceberg under this tip. And diseases that we know where that’s very clear, polio, when we have a paralytic case of polio, we know that there are one hundred to two hundred mild or asymptomatic polio infections. This is a new virus that we don’t know. What we do know is that we tested 1,700 now close contacts, and not finding, essentially all of them are negative except for the cluster that I mentioned. And the 4-year-old boy in Beijing whose laboratory [findings] are still under investigation. However, what the situation is, more broadly, we really can’t say. Is this a, you know, a severe disease where most of the iceberg is apparent because of severe illness, which was in fact more or less the case for SARS too? But this has nothing to do with SARS, as you know. But are there cases out there we have yet to find that are asymptomatic mild cases. That’s the primary focus of the investigation, is to determine whether this is in fact spreading at a lower level among humans. But there’s no evidence so far, except very rare instances.

JOURNALIST: Can I just clarify, sorry, these two clusters, which are the father and son, are the family members actually infected with H7N9 or they just got sick, I mean, have you established that?

DR MICHAEL O’LEARY: Both cases, one of the family members definitely confirmed H7N9, the other one was clinically similar, and presumed H7N9, but I think they are still actively under investigation, the second person in each case. But I think we’d have to double check that information for it because I’m not involved in the day-to-day investigation. I don’t know the exact status now of the second one in each cluster, but there were two clinical clusters, two people in each one where certainly one of them is confirmed, and the other one has similar clinical illness.

JOURNALIST: Are we overreacting to this?

DR MICHAEL O’LEARY: No, I didn’t see that of the people here today. I think this is, there’s always a legitimate concern in this kind of situation. It is legitimate concern, because we never know when the next pandemic influenza virus will arise, a virus that we do not have -- that we don’t have resistance to. So we never know when that will happen. But we have many, sort of false alarms you might say, where things arise but don’t actually go anywhere. I think it’s still very early in this investigation; it’s difficult to predict where things will go even in the short term much less the long term. The concern, the alert and concern, is not inappropriate, but we also have to be realistic, and there’s certainly no reason to panic or get overly concerned at this point.

For more information, please contact:

Ms Helen Yu
Communications Officer, WHO in China
Tel: +86 10 65327191
Email: yuji@wpro.who.int

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