Epidemiological update of 15 April: avian influenza A(H7N9) virus in China

Epidemiological update

Since the previous ECDC epidemiological update, 20 new cases of avian influenza A(H7N9) have been reported, including two fatalities in previously confirmed cases. The geographical spread includes two additional provinces: Beijing and Henan.

Since 31 March 2013, sixty cases of human infection with influenza A(H7N9) have been reported from six provinces in eastern China with a combined population of about 330 million. Onset of disease has been between 19 February and 9 April 2013 in: Shanghai (24), Jiangsu (16), Zhejiang (15), Anhui (2), Henan (2)and Beijing (1). See Figure 1 below. The date of disease onset is currently unknown for five patients. Most cases have developed severe respiratory disease and only three cases are reported to have mild clinical course. Thirteen patients died (case-fatality ratio=21%). The median age is 65 years with a range between 4 and 87 years; 17 of them are females.

The Chinese health authorities are responding to this public health event by enhanced surveillance, epidemiological and laboratory investigation and contact tracing. The animal health sector has intensified investigations into the possible sources and reservoirs of the virus. The authorities reported to the World Organisation for Animal Health (OIE) that avian influenza A(H7N9) was detected in samples from pigeons, chickens and ducks, and in environmental samples from live bird markets ('wet markets') in Shanghai, Jiangsu, Anhui and Zhejiang provinces. Authorities have closed markets and culled poultry in affected areas.

The source and mode of transmission have not been confirmed. The outbreak is caused by a reassortant avian influenza virus with low pathogenicity for birds, hence it does not cause the signal 'die-offs' in poultry associated with highly pathogenic strains of avian influenza viruses. Genetic analyses of the isolates have shown changes which suggest that the H7N9 virus may have greater ability to infect mammalian species, including humans, than most other avian influenza viruses. Pathogenicity for humans appears to be high and higher age appears to be a risk factor for disease.

The most likely scenario is that of A(H7N9) spreading undetected in poultry populations and occasionally infecting humans who have close contact with poultry or poultry products but this will have to be validated as further data become available.

At this time there is no evidence of sustained human-to-human transmission. More than 1 000 close contacts of confirmed cases are reported to have been followed up without evidence of person-to-person transmission.

There is one family cluster with two confirmed cases for which human-to-human transmission cannot be ruled out but where common exposure is the most likely explanation.

The rapid geographic spread and the increase of confirmed cases is likely to be the result of strengthened case finding and increased testing. A(H7N9) test kits have been distributed to over 400 laboratories across China and this increased ascertainment is expected to provide important epidemiological information.

An increasing incidence of sporadic cases and expansion of geographic spread in China and possibly neighbouring countries are expected over the coming weeks. Individual imported human cases to Europe cannot be ruled out and countries need to prepare for detecting and diagnosing such cases. Critical developments that would change this assessment would be evidence of sustained human-to-human transmission and detection of avian influenza A(H7N9) in bird populations in Europe.

ECDC is closely monitoring developments and is continuously re-assessing the situation in collaboration with WHO, US CDC, China CDC and other partners.

ECDC published an updated risk assessment on April 12.


Figure 1: Distribution of influenza A(H7N9) cases by province, China, as of 14 April 2013



Population, millions

Cumulative count

No of deaths

First case reported

Latest case reported

Shanghai 23 24 9 31.03.2013 14.04.2013
Jiangsu 79 16 1 02.04.2013 14.04.2013
Zhejiang 54 15 2 03.04.2013 14.04.2013


2 1 31.03.2013 07.04.2013
Beijing 30 1 0 13.04.2013 13.04.2013
Henan 94 2 0 14.03.2013 14.04.2013
TOTAL: 330 60 13 31.03.2013 14.04.2013



Figure 2: Distribution of influenza A(H7N9) cases by week of onset of symptoms, China, as of 14 April 2013


Figure 3: Distribution of cumulative number of influenza A(H7N9) cases by province, China, 19 February – 14 April 2013