H7N9 avian flu
The influenza A (H7N9) virus is one subgroup among the larger group of H7 viruses that normally circulate among birds. A number of human infections of the H7N9 virus have been reported in eastern China, mostly in the Yangtze River Delta region since late March 2013. Some of the patients have died of severe pneumonia brought on by the virus.
Echoes of Sars in bird flu panic
Families of H7N9 patients, having seen the response to the deadly new virus up close, say authorities are falling down on prevention, isolation
Ten years since Sars incubated in China and sent shockwaves around the world, another deadly new disease, H7N9 bird flu, is fuelling fear across the nation.
The similarities in its sudden appearance and spread, and the questionable response of authorities to H7N9, have people wondering whether the lessons have been learned from severe acute respiratory syndrome - which killed about 800 people around the world after it emerged from the mainland. Those decade-old lessons could prove vital in this new battle with a frequently fatal but lesser-known virus.
Many of those already caught up in the outbreak - patients, their families and poultry industry workers - are not optimistic. The authorities could be doing more, they say, adding that the fact the virus does not appear to be spreading from person to person at the moment is luck, rather than good management.
In December 2002 in Guangdong, where Sars originated, some residents were already sending text messages to friends about a mysterious new virus, but the authorities covered up the epidemic until March 2003. And, as also occurred this year, the country's new leadership took office early in March.
The H7N9 outbreak seems to have followed a path similar to that of Sars. The first H7N9 patient, an 87-year-old man in Shanghai, was admitted to hospital on February 19 and died on March 4.
On February 26, a sample from the patient was sent to a laborator authorised to deal with high-risk biological samples in the Jinshan district of Shanghai, a facility designed to trace unknown and dangerous viruses.
The sample was confirmed on March 1 as being of a new but unknown influenza virus. The H7N9 virus was extracted from the sample on March 10, an expert with the Shanghai Public Health Clinical Centre, Li Feng , was quoted as saying by the Nanfang Weekly.
It was not until March 31 that the National Health and Family Planning Commission reported that two people in Shanghai - the 87-year-old man and a 27-year-old butcher - had died, the first publicly reported human cases of H7N9 infection.
Like those who warned of the dangers of Sars a decade ago through text messages, some internet users tried to tell people about the strange illness as early as March 7, three weeks before local authorities alerted the public. A post was shared widely online that day about the first death from the unidentified disease at Shanghai's Fifth People's Hospital, prompting a response from hospital and government officials who said the preliminary diagnosis for the dead patient was flu.
But the post was deleted hours later and the next day Shanghai authorities denied the existence of any new virus. Shanghai officials acknowledged that two people had died at the hospital - an 87-year-old man and his 55-year-old son - but said the deaths were the results of lung infections and complications. It is still not known whether the son died of H7N9.
The online message was soon dismissed as a rumour and put aside by residents of the Yangtze River Delta region because of the authorities' high-profile refutation. Meanwhile, the deadly new strain of avian influenza was busy infecting dozens of residents throughout the month.
A total of 63 people have now been confirmed to have H7N9 infections, with 14 cases having proved fatal.
Officials said the delay in confirming the existence of a new virus was the result of the time it took to determine the cause of the illness.
The National Health and Family Planning Commission's statements give only the age and surnames of the H7N9 patients and the date they became feverish. No further information was available because local media and hospitals were ordered to present a united front in their public responses to the outbreak - no front-page stories, just reports with a positive angle.
Right from the beginning, the authorities have maintained there is no evidence of human-to-human transmission, a position that seems to have appeased and relaxed residents of the delta region. Few people are wearing masks in public places such as subways, buses and hospitals.
"We've heard little and thus don't feel scared. The government says we will be safe if we do not touch live poultry," a Nanjing taxi driver said.
Meanwhile, isatis root, a Chinese medicine that was rumoured to be useful against Sars, is selling quickly again, and more cities are joining those that have closed poultry markets and started culling live poultry.
While repeated reports that no evidence has been found of human-to-human transmission have tended to make residents complacent, the families of three patients told The South China Morning Post their observations of the response of authorities to the virus left them dissatisfied and fearful.
The Fifth People's Hospital in Shanghai paid the family of 27-year-old Wu Liangliang , the second person to die of H7N9 flu, 130,000 yuan (HK$161,350) in compensation on March 26, saying the payout was made on humanitarian grounds and for its minor role in Wu's treatment, without elaborating.
Wu was admitted on March 4, and the 87-year-old man died in a ward next to him that day. Wu's wife said Wu was not quarantined before he died on March 10.
"No one officially informed us of the true cause of his death until April 2," said Wu's father-in-law, Wu Demao . "It was one of our relatives who told us that the local television had reported that my son-in-law died of a new strain of bird flu."
The family of Xu Wenqin , a 45-year-old Nanjing poultry vendor who developed a fever on March 19 and was confirmed infected with H7N9 on April 2, is also concerned.
Xu Suqin , the sister of Xu, who remained in critical condition in at Nanjing Drum Tower Hospital yesterday, said: "I accept the officials' explanation for delaying the announcement of the new virus to the public. But they should, at least, have confidentially launched some epidemic-prevention measures to protect the high-risk groups.
"My sister had to slaughter chickens all day long. Her hand was full of minor wounds and she never wore a mask. She got sick about March 17. If the officials had alerted poultry vendors to be careful, telling them to wear masks or check their stock, my sister might have taken better care of herself and not have got infected. At least we could have taken her to Nanjing Drum Tower Hospital straight away, instead of wasting time seeing a doctor at a small clinic and county-level hospital."
Xu's family also criticised the authorities for failing to explain the importance of respiratory and hand hygiene and of isolating patients. Xu Wenqin was admitted to Jiangning Hospital on March 18 suffering from a cough and fever. She had developed breathing difficulties and a high fever of 40.5 degrees Centigrade by March 25. Several family members, including her 75-year-old father, two sisters, a brother and nephews, visited her at the hospital that night.
"We all think it's lucky the virus had no person-to-person transmission," Xu Suqin said. "If not, I could not bear to think of the consequences. I even flew to Beijing on March 27."
Xu Wenqin's relatives were not among the 49 people tested due to close contact with Xu, even though they had had physical contact with her when she was so sick on March 25.
"We had no idea about my sister's illness until April 2 when we heard the news on television," Xu Suqin said. "We felt scared and went to Jiangning's centre for disease control and prevention, asking the medical agency to test blood for us. But the centre just let us go and said there was no need for isolation and tests."
The husband of an H7N9 patient from Yaogou village in Shuyang county, Jiangsu province, a 48-year-old woman surnamed Sang, said public hospitals at county level should be at the front line in fighting a pandemic, but they lacked training and responded poorly.
"My wife was admitted at the county's people's hospital on March 24, and a CT scan on March 28 showed over 90 per cent of her lung was infected," the 46-year-old husband said. "The illness developed quickly and severely, but the doctors there offered no suggestions."
Nor, he said, did they think to report the case to higher authorities in Nanjing.
"I made the decision to send my wife to Nanjing Drum Tower Hospital on March 30 myself, because I thought the conditions of the county-level hospital would make saving my wife difficult," he said.
A party official from the Health Bureau of Shuyang county, who declined to give his name, said: "We were informed by a superior department on April 2 that Sang had been confirmed as having the bird flu virus. On the same day, we at once sterilised the hospital and the factory in which she worked.
"We had no idea that we were facing a new bird flu virus. If we had been aware that was the case, we would have reported the case to the provincial authorities immediately," the official said.
Being prepared to respond to emergencies has become a priority for all levels of government since Sars, and the country is now considered better equipped to deal with crises.
In 2006, the State Council set up a permanent emergency response office that reports directly to the cabinet, and the Emergency Response Law was passed the following year.
In the wake of Sars, billions of yuan have been spent on building emergency centres and hospitals for infectious diseases in central and western provinces. Another 14.3 billion yuan has been spent on an information network and on prevention and control of serious illnesses.
Sars also started a revolution in transparency. Beijing's initial failure to admit the true extent of the outbreak was roundly criticised by overseas governments and the World Health Organisation. It was two months - after devastating Sars outbreaks in Hong Kong, Singapore, Hanoi and Toronto - before Beijing allowed WHO epidemiologists to enter Guangdong on April 3 to assess the situation there.
On April 1 this year, the WHO first reported three human infections with the new influenza A (H7N9) virus in China. "We are very satisfied and pleased with the level of information shared [by the Chinese authorities]," its representative in China, Michael O'Leary, said on April 8.
But his confidence is not shared by the families of the victims. "I just think the efforts and progress are not enough, at least not enough to help my sister," Xu Suqin said. "If the virus becomes an epidemic, would it be a different story?"
Click on each balloon for more information on individual patients infected with the avian flu virus: blue, patients infected with the H7N9 virus under treatment; red, those infected with the H7N9 who have died; and pink, those with H1N1 avian flu virus.