By now you’ve no doubt heard that international health authorities are deeply concerned about a new flu strain that has surfaced in China: H7N9, which so far has sickened at least 16 people and killed six of them. The outbreak has a number of features that are troubling. It emerged rapidly; the first cases were announced five days ago, and the first death apparently occurred on Feb. 27. It is widely distributed: Confirmed cases have been found in three adjoining provinces that wrap around Shanghai, and also in Shanghai municipality itself. And it is novel: H7N9 has never been recorded in humans before.
For infectious-disease geeks, it’s that last aspect that raises a particular nervous thrill. Most of the time, most people take flu for granted, to the point of not bothering to be vaccinated against it because they assume it will not make them very sick. But every once in a while, flu defies expectations, and roars up into a pandemic: worldwide spread, high numbers of cases, high rates of death. When a pandemic occurs, almost definitionally, it is because of a new strain to which humans have no prior immunity. In human terms, H7N9 is a new strain.
This is all made more confusing because it is happening in China, an infinitely complex place with an ambivalent and contradictory attitude toward transparency. Public health has never quite recovered from the realization, 10 years ago, that the Chinese government had attempted to conceal the beginning of the SARS epidemic, which was exposed — and transmitted to the world — because a doctor from a town in southern China traveled (some say fled) to Hong Kong to attend a family wedding (some say to seek treatment he could not have gotten at home).
In the years since, some parts of Chinese public health have seemed to open up enormously: The government has threatened sellers of spoiled and counterfeit food with prosecution, and researchers have been allowed to investigate the spread of antibiotic-resistant bacteria around the country’s new mega-farms. And yet, just before this new outbreak broke open, China was being challenged for not giving clear answers to why thousands of dead pigs were showing up in its rivers.
In a weird parallel to 10 years ago, while this new flu was emerging, much of public health was looking elsewhere: at the occurrence in the Middle East of a new SARS-related coronavirus about which not enough is known. There was an ominous flu blip in 2003 as well, while SARS was burgeoning in southern China and spreading via Hong Kong to the rest of the world: A family who lived in Hong Kong, but had gone to visit relatives in Fujian, fell ill with H5N1, the flu strain that taught the world the phrase “bird flu” when it killed a Hong Kong toddler in 1997. That family’s illness in 2003 was an early sign that H5N1 had returned and was moving across the planet — but though it was much feared at the time for its pandemic potential, H5N1 never blew up in the way that was feared. (Yet.)
And H7N9 might not, as well. It is far too soon to say, despite the rapidly escalating case count and the reports — which came in while I was writing this — of a possible animal reservoir in pigeons and a possible human-to-human case. I have been writing about flu and possible pandemics since 1997 — for what it’s worth, I wrote the first story in the US in 1997 about that first H5N1 case in Hong Kong — and so at this early point, what I most want to say is this: We all love scary diseases. (If you didn’t, you wouldn’t be reading this blog.) But there is a fog of war in disease emergencies, just as there is in military ones, and it is very easy to get lost in it.
It will take a while for this story to become more clear. Anticipating that, I want to suggest some things to think about as you follow the news.
My first caution is: Remember that much of the news published in China is still reviewed by censors before being published. The Chinese government has shown encouraging transparency this week: for instance, it reported the pigeon to the OIE, the usually used French acronym for the World Organization for Animal Health, and its internal CDC quickly popped up a FAQ on this flu. Historically, those are truly unusual steps. Nevertheless, anything that comes out of mainstream media is likely to be conservative.
Second: China has a Twitter equivalent, Sina Weibo. It too, is censored, almost in real time. To avoid censorship, messages on important subjects are often written in a kind of allusive code. Machine translation does not pick this up; relying on machine translation for any Chinese reports (as most of the people you will hear talking about H7N9 in North America and Europe will be doing) is simply an invitation to error.
Third: Twitter. (Ah, Twitter.) There is going to be a lot of good on Twitter — astonishingly, the WHO said this morning that they will publish case updates to Twitter first — but there is already a huge froth of speculation and error. (One example that just flitted past me: “H7N9 hits Hong Kong!” Hong Kong has one suspected case, based on a travel history to Shanghai. Also: It’s flu season in Hong Kong.)
Fourth, and related: Don’t assume that everyone who is loading information onto their blogs or pushing it onto Twitter is doing it in a sharing spirit of helpfulness. There are people — you can see this already — who are opportunistically using this to feed their egos, angle for jobs, or generally to stir up trouble. More than ever, it’s important to be skeptical about the sources of the information you consume.
So having said that, who are trusted sources? Here is my short list: people or organizations who understand flu, have excellent sources of information, and can be relied on not to over-hype.
Reporters: Helen Branswell of the Canadian Press; Declan Butler of Nature; Martin Enserink of Science; my former colleagues Lisa Schnirring and Robert Roos at CIDRAP. (Also Mara Hvistendahl of Science, if she covers this, as she is based in Shanghai.)
Crowdsourced data: HealthMap, a huge Harvard- and Google-backed effort that combines Web-scraping with human review (also on Twitter, as is their blog editor Anna Tomasulo and their founder John Brownstein); FluTrackers, a volunteer, civilian effort that has been going since the H5N1 days.
When I have a chance, I’ll try to put together a public Twitter list of these and others whom I consider key sources. Meanwhile, try to remember Douglas Adam’s advice. More soon.