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Ninth H7N9 Death Raises Concerns
Recombinomics Commentary 20:00
April 9, 2013

Mr. Han, female, 35-year-old, Chuzhou South Qiao District residents, the onset of March 15, March 20 into the treatment of Jiangsu Nanjing , March 31 was officially confirmed human cases of infection with the H7N9 avian flu. 14:30 today, patients Mr. Han died after rescue invalid

The above translation describes the death of the third confirmed H7N9 case (35F – A/Anhui/1/2013) who was in critical condition when announced.  The death increases the total to 9.  Earlier today 4 additional confirmed cases were announced, increasing that total to 28.  WHO issued an update today which tallied 24 cases and 7 deaths.  Media reports had indicated one case (4M) had recovered.  That was was previously characterized as mild.  The recovery would be the first for a confirmed case and would lower the case fatality rate to 90%.

This high rate strongly suggests that testing is largely limited to severe cases and contacts of confirmed cases.  All four public H7N9 human sequences are now from fatal cases, and all three PB2 sequences from these cases (
A/Shanghai/1/2013, A/Shanghai/2/2013 and A/Anhui/1/2013) have E627K.  In contrast, the three avian H7N9 sequences from a pigeon, chicken, and environmental sample (A/Pigeon/Shanghai/S1069/2013, A/Chicken/Shanghai/S1053/2013, and A/Environment/Shanghai/S1088/2013) from wet markets near the first two confirmed cases in the Minghang District (see map). 

The number of confirmed avian cases has been low, raising the possibility that the avian positives reflect transmission from humans to birds, since all avian isolates have Q226L, and the E at position 627 was acquired through recombination or reassortment with other avian isolates, since E at position 627 is virtually universally detected in H7 or H9N2 isolates.  Moreover prior to this outbreak Q226L had not been reported in any H5N1 or H7 bird flu.

The high human case fatality rate continues to signal sustain human transmission via undected or unreported milder cases, WHO and CDC denials notwithstanding.

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