New Chinese flu
Aditi Tandon
AUTHORITIES worldwide are closely viewing the widespread outbreak of respiratory illness in many parts of China beginning mid-October. The root cause for concern is an increase in influenza-like illnesses (ILIs) in the country compared to the same period in the previous three years, though not higher than the peak witnessed in the winter before the December 2019 Covid-19 outbreak in Wuhan. Visuals of children with undiagnosed pneumonia filling up outpatient departments of hospitals in Beijing and Liaoning and receiving IV drips are adding to the worries of people still reeling from the impact of Sars-Cov2, first seen in China’s Wuhan in 2019 and still circulating.
Though the World Health Organisation (WHO) has advised against any travel or trade restrictions based on the current information on the event, reactions have begun surfacing. Five US Republican senators on Saturday asked President Joe Biden’s administration to ban travel between the US and China until more was known about the dangers of the new illness.
The Indian Health Ministry issued an advisory to states and UTs on November 26 for enhanced surveillance of ILIs and Severe Acute Respiratory Illnesses (SARIs) across government hospitals and testing of nasal swabs from sick children in designated ICMR labs.
Taiwanese authorities this week advised the elderly, very young and people with compromised immunity to avoid travelling to China.
The question on everyone’s mind is, could this be another pandemic?
WHAT WE KNOW SO FAR
On November 13, China’s National Health Commission reported a nationwide increase in the incidence of respiratory diseases, predominantly affecting children. The authorities attributed the increase to lifting of Covid-19 restrictions and the onset of winter, saying children are contracting pathogens that were suppressed for three years due to the effect of Covid-related non-pharmaceutical interventions such as masking and distancing.
They said the illness was due to circulating known pathogens (and nothing we do not know or cannot treat) — influenza, Mycoplasma pneumoniae, respiratory syncytial virus (RSV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Mycoplasma pneumonia, a bacterial infection, and RSV, a common virus, are known to affect children more than adults. By two years of age, more than 80 per cent of children have been infected at least once, and half of these children have had RSV twice, shows literature.
KEEPING TABS
The Chinese illness spurt became a global concern when the WHO on November 21 noted a ProMed (Programme for Monitoring Emerging Diseases) report on the widespread outbreak of an undiagnosed respiratory illness in several areas in China, requesting the country for additional epidemiologic/clinical information and lab results.
ProMed, among the world’s largest publicly available emerging diseases and outbreak reporting systems, in an alert on November 21, said, “With the outbreak of pneumonia in China, children’s hospitals in Beijing, Liaoning and other places were overwhelmed with sick children, and schools and classes were on the verge of suspension. Parents questioned whether the authorities were covering up the epidemic.”
Commenting on the disease trend, ProMed rapporteur Dan Silver says their report suggests a widespread outbreak in several areas in China as Beijing and Liaoning, both witnessing surges, are nearly 800 km apart. “It is not at all clear when this outbreak started as it would be unusual for so many children to be affected so quickly. The report does not say that any adults were affected, suggesting some exposure at the schools. ProMed awaits more definitive information about the etiology and scope of this concerning illness in China. It is too early to project whether this could be another pandemic but as a wise influenza virologist once said to me — the pandemic clock is ticking, we just do not know what time it is,” Silver explains.
CURRENT STATUS
On November 23, the WHO held a teleconference with the authorities from the Chinese Centre for Disease Control and Prevention and Beijing Children’s Hospital, in which the data they requested was provided, indicating an increase in outpatient consultations and hospital admissions of children due to Mycoplasma pneumonia since May, and RSV, adenovirus and influenza virus since October.
Following the analysis, the world body said some of these increases are earlier in the season than historically experienced, but not unexpected given the lifting of Covid-19 restrictions, as similarly experienced in other countries.
“No changes in the disease presentation were reported by the Chinese health authorities, who advised that there has been no detection of any unusual or novel pathogens or unusual clinical presentations, including in Beijing and Liaoning, but only a general increase in respiratory illnesses due to multiple known pathogens. They further stated that the rise in respiratory illness has not resulted in patient loads exceeding hospital capacities,” WHO updated the world.
Importantly, the Chinese authorities, who lifted Covid restrictions only earlier this year, have since mid-October enhanced outpatient and inpatient surveillance for respiratory illnesses covering various viruses and bacteria, and covering Mycoplasma pneumoniae for the very first time. The addition of Mycoplasma pneumoniae to the surveillance basket may have contributed to the observed increase in detection and reporting of respiratory illness in children. Based on the available information, WHO says the reported symptoms from China are common to several respiratory diseases and, as of now, all observed clinical manifestations are caused by known pathogens in circulation.
WHO ADVISORY
The WHO has not pressed the panic button yet. It has recommended that people in China follow measures to reduce the risk of respiratory illness — vaccines against influenza, Covid-19 and other respiratory pathogens; social distancing; staying home when ill; getting tested and seeking medical care as needed; wearing masks as appropriate; ensuring good ventilation; and practising regular handwashing.
“WHO does not recommend any specific measures for travellers to China. In general, persons should avoid travel while experiencing symptoms suggestive of respiratory illness, if possible; in case of symptoms during or after travel, travellers are encouraged to seek medical attention and share travel history with their healthcare provider,” the world body’s latest update says.
IMMEDIATE CONCERN
The only immediate concern appears to be Mycoplasma pneumoniae, which has risen in other countries too. “Mycoplasma pneumonia is not a reportable disease to WHO, so we tend to track this information through reporting systems and through discussions with our member states. Mycoplasma pneumonia was on the rise for the last couple of months and now seems to be a little bit on the decline. We’re following up through our clinical networks and working with clinicians in China to better understand the resistance to antibiotics, which is a problem across the world but is a particular problem in the Western Pacific and Southeast Asia region,” Maria Van Kerkhove, Director, Epidemic & Pandemic Preparedness & Prevention, WHO, said at an update briefing.
Experts say Mycoplasma pneumoniae is a common respiratory pathogen and a common cause of paediatric pneumonia, and is readily treated with antibiotics. The bacteria can lead to serious complications in some cases but in most events, patients will recover from antibiotics.
At home, a senior ICMR scientist told The Tribune that the WHO is looking at a reported resistant strain of Mycoplasma pneumoniae. This scientist noted that information flow from China tends to be viewed with scepticism, given the history of reporting on Covid-19. “We have to mount our defences. India has acted wisely by asking all states to activate disease surveillance networks, observe respiratory illness trends across government hospitals and record patient travel history in case of red flags.”
MESSAGE FOR PEOPLE
Public health experts in India are advising against panic. “There is nothing unusual in the Chinese illness spike in terms of clinical presentation or the mode of spread to suggest the arrival of something new. Crowding is actually not in ICUs or hospital rooms, but only in the OPD areas. China is seeing now what India and other countries saw when Covid restrictions were lifted,” says Kochi-based Rajeev Jayadevan, co-chairman, National IMA Covid Taskforce. Jayadevan said through the pandemic period, 2020 to 2023, around 40 million babies were born in China. “This cohort has not been exposed to common pathogens like RSV, which normally infects 80 per cent by age 2. Apart from the Omicron version of Covid, these children have not had their usual share of winter time virus infections, including influenza. During the pandemic, non-pharmaceutical interventions like masking and social distancing blocked the route of several pathogens and now these viruses are making a comeback. That is what we are seeing in China now. Put simply, these viruses are affecting a huge pool of susceptible children at the onset of winter,” Jayadevan said.
He added that the viral images of kids doing their school homework while hooked to IV drips are an expected sight. This is because seeking IV as a part of treatment even for mild ailments has been a cultural thing in China for a long time.
Asked what his message to people would be, he advised basic prevention. “If your child is sick, has a cold or cough, don’t send them to school or social gatherings. If they are unwell, see a doctor. Frequent handwashing, proper cough etiquette and judicious use of masks help reduce the spread of respiratory viruses, including influenza,” Jayadevan said.
‘Nothing to worry, but need sustained surveillance’
Leading vaccinologist and former member, National Covid-19 Task Force, Gagandeep Kang says the respiratory disease spike in China appears to have been caused by known, not new, pathogens, and that is reassuring. In an interview to Aditi Tandon, Kang — the first Indian woman to be elected Fellow of the Royal Society and more recently, the international member of US National Academy of Medicine — says the outbreak is not something we need to worry about. Excerpts:
How do you see the outbreak of respiratory illnesses in China, the first country to also report Covid-19?
What we have in China is an outbreak only in children, not affecting all ages. This usually means it is a pathogen we know. Covid-19 affected everyone. In fact, we saw it more in adults than in children. That was because it was a new pathogen. A new pathogen would worry us. Something seen in children, in general, means we have seen it before. That is reassuring.
Why is China experiencing this spurt?
This is China’s first winter since the lifting of Covid-19 restrictions. What we are seeing is most likely the effect of China having restrictions until last year and now having a release. In other countries, we saw a rise in influenza cases after the release from Covid-19 restrictions and when people started moving around.
What do we know about the outbreak?
China is saying they are not seeing anything new in diagnostic tests. It is a mix of many things. The only thing different this time is that they are testing for Mycoplasma pneumoniae (a common bacterial infection which typically affects younger children), which they were not testing before. If diagnostics are accurate, and in general China seems to spend a lot on diagnostics, we really have nothing much to worry about. We need to keep watching, see what there is and hopefully get really good diagnostic tests.
Can this be something like Covid-19?
Had it been affecting all ages, I would worry. If it had unusual clinical features, I would worry. But this is just fever, cough and cold, and nothing special. Based on information we have, this is not something we need to worry about.
What would be your advice to the government?
We should have disease surveillance running in the background all the time. Whenever there is a rise in cases in hospitals or anywhere else, we should launch a probe — what age, what tests, where did it come from. Often surveillance does not happen. This (Chinese disease spurt) hopefully will be a reminder that countries are expected to maintain stable public health surveillance to detect unusual occurrences. Disease spikes happen all the time. But we won’t catch a signal if we do not check the children who come to hospitals with coughs and colds. One can only catch a signal if there is more than usual occurrence. India’s surveillance capacity is strong. ICMR is conducting respiratory virus surveillance through Virus Research and Diagnostic Labs. My understanding is they were doing it only for adults. But now they have added children also.
Can adults get the disease which China is seeing?
If the illness is only being reported in children, chances are adults have immunity already. So it is reassuring that this is happening only in a younger population that is not so exposed to infections as against the older population that is exposed. I’ll advise people to not worry. Let public health authorities do their job.
