Random Analytics

Charts, Infographics & Analytics. No Spinning the Data. No Juking the Stats

Month: April, 2013

Random Analytics: H7N9 Infographic (to 29 Apr 2013)

***** Please note that this infographic of the Avian Influenza A(H7N9) virus was updated with public source information from late 29 Apr to early 30 April 2013 CET/EST *****

1 - H7N9_Infographic_130430(U)

Infographic Details

In the past 24-hours of reporting there have been no new cases but one new fatality. This brings the total for China to 126-cases including 24-deaths and Taiwan to 1-case without loss of life. (It should be noted that I from today I will be including asymptomatic cases, including that of a 4-year old Beijing boy which was confirmed in April. Asymptomatic cases will be represented by green figures).

Interestingly, the very late reports of the Fujian and Shandong cases from yesterday are being repeated today, thus some are discussing two new cases. Thanks so much to Crawford Kilian (@crof) for his constant updates.

To date 18.9% of all known cases have been fatal. For context the Case Fatality Rate of SARS was 10.9%.

I was able to update my database today against provincial hospital announcements and have increased my known discharges by 5. This includes the most recent discharge, as reported by Xinhua, from Henan reported today. This brings the current count of recoveries to 25 (19.8%) and asymptomatic cases to one (0.8%).

The most recent reported fatality was on the 29th April 2013 via Channel News Asia.

2 - TwoHalves_130430

A Look at Two-Halves

When I saw that the total recovered had moved ahead of the total fatalities, I thought that in itself might make a good graph, however I have noticed a pickup in discharge announcements recently so I wanted to have a look that in a bit more detail. When I cut the data in half, that is had a look at the first 63 symptomatic cases against the following 63-cases, I found two interesting data points.

The first point is around fatality figures. For the first half 28.6% of cases have been fatal, while for the second half its currently 9.5%. Although this is interesting there is a strong possibility that these percentiles will increase as more data comes in. This brings me to my second interesting data-point.

The trajectory of discharges against deaths is increasing as we see improvements in response to the H7N9 outbreak. To be more specific, to reach 12 discharges (or 19.7% of 63) it took 18-deaths for the first 50% but only six for the last 50%.

I know it’s a bit early to make too much of this split but hopefully it means we are moving in the right direction against H7N9.

Note: My previous post on this can be found at Random Analytics: H7N9 Infographic (to 28 Apr 2013)

Updates (30/04/2013)

  • After much deliberation I finally added the Beijing asymptomatic case to my dataset and adjusted the infographic and percentiles accordingly. Many thanks to Helen Branswell (@HelenBranswell) and CIDRAP (@CIDRAP) specifically Lisa Schnirring for convincing me of my error.

Random Analytics: H7N9 Infographic (to 28 Apr 2013)

***** Please note that this infographic of the Avian Influenza A(H7N9) virus was updated with public source information from late 28 Apr to early 29 April 2013 CET/EST *****

1 - H7N9_Infographic_130429(U)

Infographic Details

In the past 24-hours there have been 5 new cases (2x Jiangxi, 1 Zhejiang, 1x Fujian and 1x Shandong) with no new deaths reported. This brings the total for China to 125-cases including 23-deaths and Taiwan to 1-case without loss of life. (It should be noted that I do not include the asymptomatic Beijing case in my count).

To date 18.3% of all known cases have been fatal. For context the Case Fatality Rate of SARS was 10.9%.

There were no confirmed discharges in the past 24-hours, thus the current count of recovered remains at 20 (15.9%). Note: Prior to today when a four year old was confirmed with avian influenza A(H7N9) all known paediatrics and children had recovered.

The most recent fatality reported was on the 26th April 2013 via Jiangsu Health (in Chinese).

Final Thought

If the China Animal Agricultural Association numbers are to be believed the chicken industry will ‘in the hole’ a further ¥14,000,000,000 or according to Xinhua’s calculations would have experienced around $2.273-billion in direct losses (feeding of chickens that no one is buying, culling of chickens, lost productivity, maintenance and loss of breeding stock).

Xinhua reported that vegetable vendors are doing very well as customers change their purchasing habits to avoid chicken.

I’d also suggest that the European breed stock owners will be doing very well once the crisis is over as it sounds like the Chinese will need to do a lot of stock rebuilding.

Note: My previous post on this can be found at Random Analytics: H7N9 Infographic (to 27 Apr 2013)

Updates (29/04/2013)

  • Added another two cases (1x Fujian & 1x Shandong) which were reported by Xinhua at 23.55CET.

Random Analytics: H7N9 Infographic (to 27 Apr 2013)

***** Please note that this infographic of the Avian Influenza A(H7N9) virus was updated with public source information from late 27 Apr to early 28 April 2013 CET/EST *****

Sometime ago I was watching a documentary series on the Bikini atoll nuclear testing which included the 1 March 1954 Castle Bravo hydrogen bomb test. Due to some ‘unknown unknowns’ at the time the test was more powerful than predicted and contaminated huge amounts of the Pacific, including by chance the crew of the Diago Fukuryū Maru (Lucky Dragon 5), a Japanese fishing vessel some 40-miles (64-kilometres) away.

Now the radioactive winds were not supposed to travel in that direction, nor was the explosion predicted to be as large as it was. In some respects, the 23-crew of the Lucky Dragon 5 were just in the wrong place at the wrong time.

1 - H7N9_Infographic_130428

Infographic Details

In the past 24-hours there has been confirmation of 2 new cases. No new fatalities have been reported. This brings the total for China to 120-cases including 23-deaths and Taiwan to 1-case without loss of life. (It should be noted that I do not include the asymptomatic Beijing case in my count).

To date 19% of all known cases have been fatal. For context the Case Fatality Rate of SARS was 10.9%.

There were six confirmed discharges in the past 24-hours, all from Zhejiang which takes the confirmed recoveries to 20 (16.8%). Note: All known paediatrics and children have recovered.

The most recent fatality reported was on the 26th April 2013 via Jiangsu Health (in Chinese).

2 - SpreadOfInfection

Random Chance

If the confirmed infection area, made up of two municipalities, eight provinces and Taiwan were a country it would span a territory roughly 1.227-million km², have a population of 596.1-million and a nominal Gross Domestic Product of $5.1-trillion (USD, 2011). For context that would make it the 25th largest country for land mass (slightly larger than South Africa), the third most populous country (almost double that of the United States) with the 4th highest GDP (approximately $600Bn less than Japan) and qualify it for membership into the G20.

Yet for the massive amount of territory H7N9 inhabits it has still only made 121 people sick enough to seek treatment and killed 23-persons. Even in Zhejiang, the province with the most confirmed cases you only have a 1:1,200,000 (approximate) chance of catching the disease!

Like the fishermen on the Lucky Dragon 5, currently to get the disease (and then to die of it) you need to extremely unlucky.

One thing about statistics though, they are just that until you become a victim.

Random Analytics: H7N9 Infographic (to 26 Apr 2013)

***** Please note that this infographic of the Avian Influenza A(H7N9) virus was updated with public source information from late 26 Apr to early 27 April 2013 CET/EST *****

1 - H7N9_Infographic_130427(U)

Infographic Details

In the past 24-hours there has been confirmation of 7 new cases and one fatality. This brings the total for China to 118-cases including 23-deaths and Taiwan to 1-case without a fatality. (It should be noted that I do not include the asymptomatic Beijing case in my count).

To date 19.3% of all known cases have been fatal. For context the Case Fatality Rate of SARS was 10.9%.

Although there were no confirmed discharges in the past 24-hours, six patients from Zhejiang will be released tomorrow. That would take the confirmed recoveries to 20 (16.8%). Note: All known paediatrics and children have recovered.

The most recent fatality reported was on the 26th April 2013 via Jiangsu Health (in Chinese).

2 - DeathByAge_130427(U)

Age at Death

Chinese media today reported the death of one of the earliest victims, a 32-year old woman from Jiangsu and confirmed the death 76-year old farmer from Zhejiang.

Of the 22-cases where death has been verified the average age was 64-years and 54.5% of the deaths were recorded in those over the age of 65. It should be noted that two deaths cannot be verified at this stage.

The youngest person to die was a 27-year old butcher from Shanghai with a history of hepatitis B. Being amongst the first victims of the disease he did not receive antiviral treatment until the second week (the recommended window for this treatment should be two days) and succumbed to the disease after 12-days.

At the other end of the age spectrum the oldest person to die at this stage was the first known victim, an 87-year old retiree from Shanghai who became ill on the 19th April and passed away on the 4th March. As an aside, his two younger sons (aged 69 and 55) also became ill around the same time. The younger one also succumbed to the disease while the older one has recovered. This could then be the first family cluster (although I leave it to those more knowledgeable to discuss).

Final Thought

Fujian is the 10th municipality or region to have a confirmed case. Although the case count is very low the spread of this respiratory disease must be concerning, especially given that the victims cover a landmass of more than a million square kilometres and house a population in excess of half a billion people.

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Updates (28/04/2013)

  • Correction. I double counted a death when I first published this blog and although publically available missed a confirmed      fatality update. All infographics updated accordingly along with the details (in bold).

Random Analytics: H7N9 Infographic (to 25 Apr 2013)

***** Please note that this infographic of the Avian Influenza A(H7N9) virus was updated with public source information from late 25 Apr to early 26 April 2013 CET/EST *****

1 - H7N9_Infographic_130426(U)

Infographic Details

In the past 24-hours there has been confirmation of 3 new cases and no additional fatalities. This brings the total for China to 111-cases including 23-deaths and Taiwan to 1-case without a fatality. (It should be noted that I have not included the suspected Jiangxi case as it has not been confirmed by the Centre for Health Protection or the asymptomatic Beijing case in my count).

To date 20.5% of all known cases have been fatal. For context the Case Fatality Rate of SARS was 10.9%.

There were no confirmed discharges in the past 24-hours. The confirmed recoveries remain static at 14 (12.5%). (Note: I have also made a change to the infographic to track paediatrics and children. 0 – 2 year olds will be shown as a baby symbol and 3 – 12 year olds will be shown as a small girl/boy symbol.)

The most recent fatality reported was on the 24th April 2013 via Xinhua.

I’m a Workforce Analyst (doing an Economics Masters) so one of the metrics I have been tracking is what confirmed cases do for employment. Currently I have 72-inputs and as shown in the infographic the top five employments were Retired, Farmer, Unemployed, Live Poultry Trade and Chef/Cook.

The Lancet today suggested that avian influenza A(H7N9) comes from wet market chickens (for a brief overview I’d suggest viewing Crawford Killian H5N1 update with relevant links). Given the high average age of those presenting and the fact that they would do a lot of food preparation you can start to see a confluence of data to support that. Of the five top job titles, four would have significant exposure to chickens.

Here’s a look at the top 20 incidences by job title (I have not included 3 confusing data inputs due to machine translation issues. For interest only they are 1x company employee and 2x freelance (and if anyone out there can translate these please send me a tweet @gmggranger).

2 - JobTitle_130426

Final Thought

I’m only a recent China watcher but many economists that I follow and talk to agree that Chinese economic data needs to have the ‘trust and verify’ test before it can be validated and utilised for analysis. If you need some more background on this then Stephen Koukoulas, an Australian economist and former advisor to the current Prime Minister Julia Gillard discussed this recently in a Business Spectator article.

Unfortunately the avian influenza A(H7N9) will not have a lot of outside inputs to China that can be verified and tracked. With numbers of new victims levelling off somewhat in recent days I’d be interested to see what happens outside of China, especially in Taiwan or another East Asian country if the virus spreads further.

Random Analytics: H7N9 Infographic (to 24 Apr 2013)

***** Please note that this infographic of the Avian Influenza A(H7N9) virus was updated with public source information from late 24 Apr to early 25 April 2013 CET/EST *****

1 - H7N9_Infographic_130425

Infographic Details

In the past 24-hours there have been no reported cases but one more fatality which brings the total for China to 108-cases including 23-deaths.

For the first time a case has been reported outside of mainland China. Taiwan reported that a 53-year old man (with underlying health issues) had the condition. He had returned from Suzhou, Jiangsu Province on the 9th April, became symptomatic three days later and was hospitalised in Taiwan on the 16th April.

21.1% of all known cases have been fatal so far. For context SARS was 10.9%.

There were no confirmed discharges in the past 24-hours. The confirmed recoveries remain static at 14 (12.8%).

In another interesting development the first potential case has been reported by Xinhua in Jianxi province, although this has not been confirmed by the Centre for Health Protection. Jiangxi is located in East China next to the Zhejiang which still has the most confirmed victims at 42 (including six deaths).

2 - ChinaRegions_Detailed

The most recent fatality reported was on the 24th April 2013 via Xinhua.

Final Thought

The movement of the virus from China to Taiwan on an airplane, although troubling was to be expected, especially given the amount of inbound travel from the mainland. According to Taiwan Holidays around 1.06-million mainland Chinese visited the island between January and May 2012.

This is the first confirmation of movement of the virus outside of China and as a development it is one to watch.

Updates (25/04/2013)

  • I have updated the fatalities paragraph after an excellent suggestion by @influenza_bio. Here are the points that he raised via Twitter.

T - 130425_@influenza_bio

Random Analytics: H7N9 Infographic (to 23 Apr 2013)

***** Please note that this infographic of the Avian Influenza A(H7N9) virus and was updated with public source information from late 23 Apr to early 24 April 2013 CET/EST *****

Just a quick infographic update today.

1 - H7N9_Infographic_130424

Infographic Details

In the past 24-hours there have been three more cases and one more fatality which brings the total to 108-cases including 22-deaths. This equates to a case fatality rate of 20.4%. For context SARS was 10.9%. (Note: I have updated the SARS link from the last WHO update in 2003 to a more detailed National Centre for Biotechnology Information paper from 2010. Thanks to Helen Branswell (@HelenBranswell) for providing the link.)

There has been one confirmed discharge in the past day from Henan and yesterday Sina confirmed a further three patients were discharged on Sunday. This brings the confirmed recoveries up to 14 (13%) and the mystery outpatients to just three (down from six yesterday).

The most recent fatality reported was on the 23rd April 2013 via Xinhua.

Final Thought

Helen Branswell made a good point via Twitter yesterday that the low amount of confirmed discharges might be lost between the various provincial hospitals.

I’ve appended her very good comments.

T - 130422_@HelenBranswell

Random Analytics: H7N9 Analytics (to 22 Apr 2013)

***** Please note that this post reflects data, graphs and infographics of the Avian Influenza A(H7N9) virus and was updated with public source information from late 22 Apr to early 23 April 2013 CET *****

 

The avian influenza A(H7N9) virus which first struck Shanghai in mid-February when an 87-year old Shanghai resident fell ill with flu/pneumonia like symptoms, then subsequently died two-weeks later continues to cause disruption in China.

Like previous outbreaks of respiratory disease, this new strain designated by the World Health Organisation (WHO) as avian influenza A(H7N9) has the potential to cause major issues for the World’s second largest economy and like SARS previously to spread internationally.

It should be noted that I’m not a medical specialist (although I did spend a very happy year working in an Operating Room Suite as an Anaesthetic Secretary). I do love data so each day (when available) I’ll try to present a range of analytics using the most recent information so that you can tap into this event with some evidenced based data.

Case Fatality Rate

In the past 24-hours there have been three more cases and one more fatality (preliminary, still awaiting confirmation from the WHO) which brings the total to 105-cases including 21-deaths. This equates to a case fatality rate of 20%. For context SARS was 10.9%.

There was one confirmed patient discharge and I was able to review the data again to add a further 3 discharges, thus bringing the confirmed recoveries up to 13 (12.4%).

The most recent fatality reported was on the 22nd April 2013 via Shanghai Health Department (thanks to Michael Coston for the tip).

Here is an infographic looking at those being treated, fatalities and patients that have been discharged from treatment. Where I have been able to confirm the details I have broken the groups into male/female sub-groups.

1 - H7N9_Infographic_130423

Epidemiology

The next graph is an epidemiological analysis of cases, including deaths and patients who have recovered using the onset of the illness. Currently I have been able to verify the illness onset dates of 100-patients all of which have been included in the following graph.

I was also able confirm all of the ranged onset date ranges via the Chrome translation tool which will have stabilised the data a little further, especially now we are getting to a decent sampling size.

Possibly controversially I have decided to input the two sons (one of whom died, one recovered) who potentially contracted the disease within a family cluster from the last known date range they were admitted to hospital for pneumonia (19 – 24 February 2013).

Please note that WHO issue a similar report on a weekly basis.

2 - EpedemioCurve_130423

Cases by Municipality/Province

The next infographic is a look at the 105-cases by Municipality (in the case of Beijing and Shanghai) or Province.

At this stage the bulk of the official reported cases have been in the Zhejiang Province (38.1%) followed by the Shanghai Municipality (32.4%) and Jiangsu (21.9%).

At a regional level the cases are almost entirely confined within the East China Region (96.2%), represented by the blue section in the infographic.

The big story today will be the first instance of avian influenza A(H7N9) in the Shandong Province and the slow spread outside of Shanghai.

Prior to this in East China only Henan and Beijing had recorded instances of H7N9, although to date no deaths have been reported in these areas.

Presentations by Age Group

Here is a look at those presenting with avian influenza A(H7N9) by their age cohort.

Of the 102-cases where age data is known the average age was 58.3-years and 45.1% of the patients were aged 65 or greater.

Currently only four cases were under the age of 24, three children (ages 2, 4 and 7) and a 21-year old female from Jiangsu. I have not included the 4-year old asymptomatic case in Beijing reported in mid-April.

4 - PresentationsByAge_130423

Age at Death

Of the 19-cases where death has been verified the average age was 63.3-years and 52.6% of the deaths were recorded in those over the age of 65.

The youngest person to die was a 27-year old butcher from Shanghai with a history of hepatitis B. Being amongst the first victims of the disease he did not receive antiviral treatment until the second week (the recommended window for this treatment should be two days) and succumbed to the disease after 12-days.

5 - DeathByAge_130423

Summary

Not much analysis today, it was all about double checking and cleansing the data I had and reviewing source material (a hard grind).

Updates (23/04/2013)

  • Updated the WHO SARS case fatality rate with a later study that put the CFR at 11.9% (not 9.6%). Many thanks to Helen Branswell (@HelenBranswell) for picking this up.

Random Analytics: H7N9 Analysis (to 21 Apr 2013) Short Version

***** Please note that this post reflects data, graphs and infographics of the Avian Influenza A(H7N9) virus and was updated with public source information between 21– 22 April 2013 *****

 

The avian influenza A(H7N9) virus which first struck Shanghai in mid-February when an 87-year old Shanghai resident fell ill with flu/pneumonia like symptoms, then subsequently died two-weeks later continues to cause disruption in China.

Like previous outbreaks of respiratory disease, this new strain designated by the World Health Organisation (WHO) as avian influenza A(H7N9) has the potential to cause major issues for the World’s second largest economy and like SARS previously to spread internationally.

I’m not a medical specialist but I do like data so each day (when available) I’ll try to present a range of analytics using the most up to date public and primary sourced information available so for any interested parties they can get an evidenced based snapshot of the evolving situation.

Case Fatality Rate

In the past 24-hours there have been 102-cases including 20-fatalities. This equates to a case fatality rate of 19.6%. For
context SARS was 10.9%.

9 persons (8.8%) are known to have recovered and have been discharged from hospital or treatment.

The most recent fatalities reported were on the 21st April 2013 via Xinhua and WHO.

Here is an infographic looking at those hospitalised, confirmed fatalities and patients that have had confirmed recoveries. Where I have been able to confirm the details I have broken the groups into male/female sub-groups.

1 - H7N9_Infographic_130422

Epidemiology

The next graph is an epidemiological analysis of cases, including deaths and patients who have recovered where I have been able to verify the onset of illness. Currently I have been able to verify the illness onset dates of 91-patients which have been included in the following graph. (Note: Where a range of dates for onset of avian influenza A(H7N9) have been used I have input the earliest date until I can verify the actual onset).

Please note that WHO issue a similar report on a weekly basis.

2 - EpedemioCurve_130422

Cases by Municipality/Province

The next infographic is a look at the 102-cases by Municipality (in the case of Beijing and Shanghai) or Province.

At this stage the bulk of the official reported cases have been in the Zhejiang Province (37.3%) followed by the Shanghai Municipality (33.3%) and Jiangsu (22.6%).

At a regional level the cases are almost entirely confined within the East China Region (96.1%), represented by the blue section in the infographic.

Outside of the East China only Henan and Beijing have recorded instances of H7N9, although to date no deaths have been reported in these areas.

Analysis: Shanghai was the originating municipality and had the bulk of the provincial cases. During the period 20 – 21 April the neighbouring province of Zhejiang equaled Shanghai for case numbers (33 each) and the most recent announcements have stretched this further (38 compared to 34).

Also worth noting that currently Zhejiang has a much lower percentile of fatalities (13.2% against 32.4%). Being at the epicentre of the outbreak while the disease was an unknown could be an explanatory factor in the much higher Shanghai case fatality rate.

3 - CasesByRegion_130422

Presentations by Age Group

Here is a look at those presenting with avian influenza A(H7N9) by their age cohort.

Of the official 98-cases where age data is known the average age was 59.3-years and 45.9% of the patients were aged 65 or greater.

Currently only four cases were under the age of 24, three children all under the age of 10 and a 21-year old female from Jiangsu. This does not include the 4-year old asymptomatic case in Beijing reported in mid-April.

Analysis: A definite and steady trend that this respiratory disease is targeting older cohorts and men especially. For those aged 65 or over the male to female ratio is 2.75:1

4 - PresentationsByAge_130422

Age at Death

Of the 16-cases where death has been verified the average age was 61.3-years and 43.8% of the deaths were recorded in those over the age of 65.

The youngest person to die was a 27-year old butcher from Shanghai with a history of hepatitis B. Being amongst the first victims of the disease he did not receive antiviral treatment until the second week (the recommended window for this treatment should be two days) and succumbed to the disease after 12-days.

5 - DeathByAge_130422

Summary

With the new information made available over the past 24-hours, the item of most interest data-point is the ascendancy of Zhejiang in terms of case numbers, overtaking Shanghai for the first time.

What is also noteworthy is the lack of town/city detail of the victims of that province that has been provided to the public via official or semi-official means (i.e. Xinhua). Zhejiang has had 38-cases to date but I’ve only come across one primary sourced reference to a city (Huzhou) while neighbouring Jiangsu with 23 cases has provided eight city level locations.

I’m not a China expert so if anyone has a reasonable answer to this lack of detail around Zhejiang please drop me a line via Twitter (@gmggranger)

I/O

Response from Crawford Kilian (@Crof) via his H5N1 blog:

The answer, I suspect, lies in a tedious search through Google-translated reports from Zhejiang Chinese media…

There he details, in some detail five recent Zhejiang cases via Hangzhou Ribao before stating:

My point is that this one report gives the location of each of the recent cases, and a diligent search should turn up earlier cases. Maybe some of these people were shipped in to hospitals in Hangzhou from rural districts (or not – Chinese cities don’t always distinguish between rural and urban). But we amateur epidemiologists should be content with gaining a sense of where these cases are being treated.

Fantastic advice! I totally agree Crawford and I’ll be tracking down some of this legacy detail in coming days to flesh out my database.

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Updates (22 Apr 2013)

  • Added I/O section with Zhejiang response from Crawford Kilian:
  • Corrected all instances of Mortality Rate to Case Fatality Rate. Tks to Ramon Hernandez (@HlthAnalysis) for picking this up.

Updates (23/04/2013)

  • Updated the WHO SARS case fatality rate with a later study that put the CFR at 11.9% (not 9.6%).

Random Analytics: Avian Influenza A(H7N9) Virus (to Sun 21 Apr 2013)

***** Please note that this post reflects data, graphs and infographics of the Avian Influenza A(H7N9) virus situation in China and was updated with available information between 17th April through to the early morning of 22 April 2013 (CET) *****

Before I commence it should be noted that avian influenza A(H7N9) is not the Spanish Flu which spread to one in every four persons on Earth and killed between 2.5 – 5% of the world’s population.

Currently, due to the low amount of cases and its lack of country-to-country movement it is not even comparable to the SARS breakout which had a case fatality rate weighted in the hundreds, reached dozens of countries and had a significant global economic impact measured in the tens of billions of dollars.

Although it is an emergent flu virus, it is now a confirmed killer being actively tracked by several organisations including the China Health and Family Planning Commission and the World Health Organisation (WHO).

All diseases have both health and economic impacts and it is worthwhile keeping a weather eye on those being followed by global health organisations.

Avian Influenza A(H7N9) Virus

On the 5th April 2013 the WHO posted on its website:

In the past few weeks, WHO has received from China reports of human infection with influenza A(H7N9) virus. The influenza A(H7N9) virus is one subgroup among the larger group of H7 viruses, which normally circulate among birds.

Human infections with other subgroups of H7 influenza viruses (H7N2, H7N3, and H7N7) have previously been reported in the Netherlands, Italy, Canada, United States of America, Mexico and the United Kingdom. Most of these infections occurred in association with poultry outbreaks. The infections mainly resulted in conjunctivitis and mild upper respiratory symptoms, with the exception of one death, which occurred in the Netherlands.

These recent reports from China are the first cases of human infection with H7N9 viruses.

Clinical presentation

The main clinical feature among most patients is respiratory diseases resulting in severe pneumonia. Symptoms include fever, cough and shortness of breath. Patients have required intensive care and mechanical ventilation. Information is, however, still limited about the full spectrum of disease that this infection might cause.

It should be noted that from mid-April the WHO was starting to see some “relatively mild cases of illness” and that “it is possible that there are other such cases that have not been identified and reported.” The Chinese Health and Family Planning Commission also announced that it would reimburse rural H7N9 sufferers via a Rural Cooperative Medical System, hopefully alleviating any direct costs of treatment at the same time increasing both data capture and knowledge of the disease.

Here are some analytics of the avian influenza A(H7N9) virus outbreak.

Epidemiological Curve and Case Fatality Rate

What would most concern the relevant authorities is the very high case fatality rate in the first weeks and months of the outbreak.

Currently there are 102 laboratory confirmed cases including 20 confirmed fatalities, a mortality rate of 19.6%. For context SARS was 10.9%.

9 persons (8.8%) are known to have recovered and have been discharged from hospital or treatment.

The most recent fatality via Xinhua was on the 21st April.

Here is an infographic looking at those hospitalised, confirmed fatalities and patients that have had confirmed recoveries. At the suggestion of @vanebobadilla I’ve also included breakdowns by sex using the most current available data (see embedded notes for details).

1 - H7N9_Infographic_130422

Using public sourced data here is a look at the epidemiological curve of cases where I have a confirmed onset of illness date. If I can then verify the subject has died or recovered I have coloured them accordingly. WHO issue a similar report on a weekly basis. Currently I have been able to verify the illness onset dates of 91-patients which have been included in the following graph. (Note: Where a range of dates for onset of avian influenza A(H7N9) have been used I have input the earliest date).

2 - EpedemioCurve_130422

Cases by Municipality/Province

Now a look at the 102-cases by Municipality (Beijing/Shanghai) or Province.

At this stage the bulk of the official reported cases have been in the Zhejiang Province (37.3%) which overtook the Shanghai Municipality (33.3%) for number of cases on 21 April 2013. At a regional level the cases are almost entirely confined within the East China Region (96.1%), represented by the blue section in the infographic.

Outside of the East China only Henan and Beijing have recorded instances of H7N9.

In Beijing a seven year old girl became ill with the respiratory disease on the 11th April 2013, presented to a hospital two days later and was released from Beijing Ditan Hospital on the 17th April having fully recovered.

On the 14th April the first asymptomatic case was recorded with a 4-year old Beijing boy being tested positive as part of a high-risk surveillance group.

The most recent case outside of East China was recorded on the 18th April in Henan Province, South Central China.

3 - CasesByRegion_130422         

Presentations by Age Group

Here is a look at those presenting with avian influenza A(H7N9) by their age cohort.

Of the official 98-cases where age data is known the average age was 59.3-years and 45.9% of the patients were aged 65 or greater. Only four cases were under the age of 24, three children all under the age of 10 and a 21-year old female from Jiangsu. This does not include the 4-year old asymptomatic case in Beijing reported in mid-April.

4 - PresentationsByAge_130422

Age at Death

One of the explanations of the high mortality rate might be the high average age of those presenting to medical facilities.

Of the official 16-cases where death has been officially confirmed and verified the average age was 61.3-years and 43.8% of the deaths were recorded in those over the age of 65.

The youngest person to die was a 27-year old butcher from Shanghai with a history of hepatitis B. Being amongst the first victims of the disease he did not receive antiviral treatment until the second week (the recommended window for this treatment should be two days) and succumbed to the disease after 12-days.

5 - DeathByAge_130422

I/O

19/04/2013: I had an interesting discussion via Twitter with Jason Tetro (aka The Germ Guy). I’m a data specialist so needed to do some ancillary reading in relation to his input but Jason raised the subject that the H7N9 might cause a cytokine storm, effectively an uncontrolled immunity feedback loop. I’ve included links to both Jason’s blog and the relevant Wikipedia page.

T - 130419_@JATetro

In Summary

The avian influenza A(H7N9) virus is a new and as yet relatively unknown disease.

Some of its predecessors, like the Spanish flu (H1N1 from 1918-1919) or the Asian flu (H2N2 from 1956 – 1958) had devastating impacts. More recent variants such as the Avian Flu (H5N1 from 2003) and the Swine Flu (H1N1 from 2009) were less lethal comparatively.

Before I close it might be worthwhile to look at a recent and quite lethal respiratory disease outbreak, the H7N9 virus, commonly known as SARS.

The Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) was a viral respiratory disease, which initially struck China but eventually impacted up to 37 countries between November 2002 and July 2003. From the onset of the disease the World Health Organisation (WHO) confirmed that it infected 8,096 people including 774 fatalities, a mortality rate of 9.6%.

According to the WHO in its 49th update of the SARS virus (7 May 2003) “the likelihood of dying from SARS in a given area has been shown to depend on the profile of the cases, including the age group most affected and the presence of underlying disease. Based on data received by WHO to date, the case fatality ratio is estimated to be less than 1% in persons aged 24 years or younger, 6% in persons aged 25 to 44 years, 15% in persons aged 45 to 64 years, and greater than 50% in persons aged 65 years and older.

From an economic viewpoint the Asian Development Bank did some modelling during the tail-end of the outbreak and stated that the disease would cause around $12.3 billion in lost Gross Domestic Product in its first quarter, ramping up to $28.4 billion in a second consecutive quarter for East and South East Asia alone. This was mainly due to losses in import demand (air travel, entertainment, retail, tourism and transportation) and confidence. The total global cost of the SARS was estimated to be between $40 and $50-billion.

Given both the health and economic risks associated with any disease outbreaks, especially those coming out of the Middle Kingdom, I will be closely monitoring the developments of this new respiratory disease and updating this post regularly as more data comes to hand.

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Updates (17/04/2013)

  • Initial blog with three infographic sections posted with data confirmed by WHO correct as at 17/04/2013 (77 confirmed cases, 16 deaths);

Updates (18/04/2013)

  • As per the WHO ‘Standardisation of the influenza A(H7N9) virus terminology 16 April 2013 document the name of the disease has been updated from influenza A(H7N9) to avian influenza A(H7N9);
  • Updated Cases by Municipality/Province, Mortality Rate and Presentations by Age sections after five new cases (82) and one new fatality (17) were updated via Xinhua.

Updates (19/04/2013)

  • Updated Cases by Municipality/Province, Mortality Rate and Presentations by Age sections after four new cases (87) were updated via Xinhua;
  • Added the Age at Death section;
  • Added the I/O (Input/Output) section.

Updates (20/04/2013)

  • Updated Cases by Municipality/Province, Mortality Rate and Presentations by Age sections after four new cases (91) were updated via Xinhua;
  • Replaced Mortality Rate section with a dual Epidemiological Curve Bar Chart/Mortality Rate Line Graph.

Updates (21/04/2013)

  • Updated Cases by Municipality/Province, Epidemiological Curve and Mortality Rate, Presentations by Age and Death at Age sections after five new cases (96) and one new fatality (18) were updated via Xinhua;
  • Added the H7N9 Infographic to the Epidemiological Curve and Mortality Rate section (which has been promoted to the first section).

Updates (22/04/2013)

  • Updated H7N9 Infographic, Cases by Municipality/Province, Epidemiological Curve and Mortality Rate, Presentations by Age and Death at Age sections after six new cases (102) and two new fatalities (21) were updated via Xinhua and WHO);
  • Corrected all instances of Mortality Rate to Case Fatality Rate. Tks to Ramon Hernandez (@HlthAnalysis) for picking this up.

Updates (23/04/2013)

  • Updated the WHO SARS case fatality rate with a later study that put the CFR at 11.9% (not 9.6%);