Avian influenza A(H7N9) virus case data in humans: more chicken scratchings

This is an example of a 2015 case announcement from the World Health Organization (WHO). I think it aims to provide information on some avian influenza A(H7N9) cases that occurred in China.

From WHO Disease Outbreak News (DON) at
http://www.who.int/csr/don/15-june-2015-avian-influenza-china/en/

I suppose it does do that in the most basic sense. Yes, if you were a casual electronic browser to the WHO disease outbreak news site (...get out more!) then you would learn of 15 additional human cases of disease presumably due to H7N9 infection. Twenty percent of these cases died and this happened within a month. 

But consider these questions for a moment:

1. Why would you visit the WHO to learn of this, if you were not seeking some actual detail and evaluation of risk?
2. If you were a casual browser, I expect you would come away from this with some out-of-context concerns about a bolus of cases in such a short period, spanning a wide age range and occurring across considerable geographic distance. Should you be worried? Is this the precursor to some larger outbreak? Each difficult to answer from this very small cross-section of information.
3. These public data are relied upon by some when they write papers or release infectious disease reports - so why not include key - yet deidentified - demographic detail in a line list format - remember MERS-CoV in South Korea anyone? That WHO list [4] was messy [5] but it was a step forward for those outside the WHO network who wanted free, publicly available basic data, quickly

In my opinion, the premier emerging disease tracking and publishing - at least in terms of accessible, basic, rapid, searchable, freely accessible and up-to-date emerging infectious disease information - is the team at FluTrackers. Keep your predictive modelling - I'd trade it all in for a clone army of these guys any day! The FluTrackers line list on H7N9 includes some of these cases[6]...and as you can see in the snippet below, even their scouring of the media from China does not help to fill in the data gaps on these cases...

From FluTrackers' H7N9 line list at
https://flutrackers.com/forum/forum/china-h7n9-outbreak-tracking/143874-flutrackers-2013-15-human-case-list-of-provincial-ministry-of-health-government-confirmed-influenza-a-h7n9-cases-with-links?t=202713 [6]

So why does the WHO bother with this information at all? I can't speak for them. But one reason may be because it is relied upon by those who study and prepare for the emergence of new or re-emergence of old infectious agents.[1] These people consume this sort of information to track what's happening outside their own back yard and to weigh the risks that a new bug may come knocking at the gate thanks to a speedy international plane flight. But when the host country is slow or perhaps even reticent to identify key case details, a knowledge gap emerges and may widen. This particular gap has been growing since 2014's H7N9 3rd wave. Perhaps since the 2nd wave.

When sufficient - or any - detail is lacking, then it comes down to the public to look for any answers they seek...by themselves. In this case, that has been FluTrackers & Co; this source has proven itself very worthy for this and for other viral threat monitoring, but cannot be expected to fill this need indefinitely.[2,3]

H7N9 is a good example of an absence of obvious change to the flow of information that the world's public, citizen scientists and its more professional scientists receive about new infectious threats. And this is all a bit strange because I was sure we'd heard a lot about the need to do much, much better on this sort of tracking and chatting in 2014/5 during one of the biggest modern moments of being "caught with our pants down" - the Ebola virus disease epidemic.

Time and viruses wait for no person. Be faster.

Ho. Ho. Ho.

References...

1. http://ecdc.europa.eu/en/publications/Publications/RRA-Influenza-A-H7N9-update-four.pdf
2. http://www.ncbi.nlm.nih.gov/pubmed/24885692
3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140362/pdf/jphr-2012-2-e29.pdf
4. http://www.who.int/emergencies/mers-cov/MERS-CoV-cases-rok.pdf?ua=1
5. http://virologydownunder.blogspot.com.au/2015/06/matching-mers-case-identification.html
6. https://flutrackers.com/forum/forum/china-h7n9-outbreak-tracking/143874-flutrackers-2013-15-human-case-list-of-provincial-ministry-of-health-government-confirmed-influenza-a-h7n9-cases-with-links?t=202713

Case->outbreak->epidemic->publication->learn a lesson...repeat

The global cumulative curve of suspect+probable+confirmed
cases EVD cases (orange) , suspect+probable+confirmed
EVD deaths (red) and the confirmed cases (yellow dots)
Updated from last WHO data posted 10JAN2015 AEST.
Click on image to enlarge.

When looking at the PubMed database search results for 'ebola', one can have no doubt that something big must have happened lately to drive such a massive number of science doers and writers to their keyboards. 

And of course something did - the world's largest, most widespread, multinational and longest running epidemic of Ebola virus disease (EVD) which roared through Guinea, Sierra Leone and Liberia. At the end of 2014 there were 20,000 cases and 8,000 fatalities - and those were just the cases we have seen added to official lists and made public.

A tally downloaded from the PubMed search engine
based on numbers returned using the search term 'ebola'.
Click on graph to enlarge.

The adjacent image shows what the US National Library of Medicine's search engine generates when one searches for 'ebola'. The search engine, called PubMed because it makes the MEDLINE database public (MEDLINE being the Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), lists many of the world's life science and biomedical publications that meet the PubMed standards; currently >24,000,000 citations. In 2014, a lot was written about EVD.

While a lot of the 'ebola' publications in 2014 were commentaries and a lot of reviews that mostly presented the same information, these were necessary to feed many different groups of readers and specialities hungering for background on EVD and the ebolaviruses and how these related to them and their roles, patients and lives. 

I had cause to scan the literature on a daily basis for a few weeks and was particularly impressed with the New England Journal of Medicine's clinical papers and the BMJ's summaries and updates. Of course Science/Sciencexpress and Nature had some beautifully informative articles as well - delving into the humanity behind the numbers and seeking answers to questions we were all asking. I thought PLOS Current Outbreaks (although I'll never enjoy reading that layout), Lancet, Lancet Infectious Diseases and Morbidity and Mortality Weekly Report also stood out in 2014. 

Some of these articles came out very quickly and many were available without the need to breach a paywall. But some of the research...I can't help but wonder how many lives could have been saved if studies detailing and reinforcing the apparent benefits to survival from the aggressive use of intravenous fluids and electrolytes could have come out sooner-through whatever venue. What if we'd talked about, researched or actually published better personal protective gear designs earlier? Imagine if the world had registered that Ebola virus seemed to be in the region years ago, when research papers suggested it. Would any of this knowledge have saved more lives? Who knows? Would the focus on what needed to be delivered to West Africa have changed because of earlier dissemination of need? Would more point of care chemistry instruments have been prioritised? Would the urgency about the need for more healthcare workers have been stepped up if more specific examples of why they were needed were out there for our leaders to be briefed on? Probably unanswerable questions.

Why can't humans ever seem to learn enough to prevent the event sneaking up and whacking us senseless? Why is it always after the event that the light dawns and processes are created for 'next time'?

There will be many more publications to come in 2015, spinning out of this epidemic and the events yet to unravel. Hopefully they will create enough memory for the world to be better prepared for next time. Prepared for a little...uooh - goober fish...