History and exam

Key diagnostic factors

Present in most hospitalised patients and can be dry or productive. Haemoptysis was reported in 25% patients in one series.

Non-specific symptoms that are often associated with influenza including cough, fever, headache, myalgia, and fatigue have been reported in some clinically mild cases and as the initial symptoms prior to progression to lower respiratory tract disease. Sore throat and rhinorrhoea appear to be less likely.

Present in over 50% of hospitalised patients in a large published series.

Usually temperature >38°C (>100.4°F) occurs early in the course of illness and may persist, especially with severe illness, but an absence of pyrexia does not exclude the possibility of infection.

Frequency unknown, but common auscultatory finding in severe illness caused by other influenza A viruses. Signals decreased air movement through a part of the lung or lungs, and could indicate pulmonary consolidation, atelectasis, effusion, or acute respiratory distress syndrome.

Frequency unknown, but common finding in severe illness caused by other influenza A viruses.

Other diagnostic factors

Non-specific primary gastrointestinal symptoms have been reported in some A(H7N9) virus-infected patients.

Non-specific neurological symptoms have been reported.

Risk factors

Many (but not all) patients with Asian lineage A(H7N9) virus infection report having visited or worked at a live poultry market in China. Some low-pathogenic avian influenza (LPAI) A(H7N9) virus-infected patients reported having direct or close contact with backyard poultry in rural areas of China. Most animal exposures involved poultry, but exposures to other birds and mammals have been reported.[7] Asian lineage A(H7N9) virus has been detected in chickens, ducks, and pigeons, but not in pigs. Asian lineage A(H7N9) virus RNA has been detected in goose meat and also in sewage obtained from a wet market.

As of February 2019, 40 case clusters of Asian lineage A(H7N9) virus infection have been reported since 2013, with most of the clusters containing no more than two individuals. Epidemiological investigations of family clusters suggest that most cases of Asian lineage A(H7N9) virus infection had poultry exposures. However, close and prolonged unprotected exposure, including providing basic care to an index case, is the most likely explanation for limited, non-sustained human-to-human transmission in some clusters; this has been reported after prolonged unprotected exposures in blood-related family members and in unrelated people, including nosocomial transmission (patient-to-healthcare worker, and patient-to-patient). The risk of human-to-human A(H7N9) virus transmission was similar during 2013 to 2017 and remains low.[11]

Transmission of Asian lineage A(H7N9) virus to laboratory workers is not known to have occurred when appropriate laboratory health and safety measures have been followed.

Biosafety level 2 practices and procedures are the minimum requirement for handling specimens suspected to contain Asian lineage A(H7N9) virus.[111] Biosafety level 3-enhanced containment standards are the minimum requirement for culture of suspected Asian lineage A(H7N9) virus.[111] A small serological survey of laboratory workers exposed to highly pathogenic avian influenza (HPAI) A(H5N1) virus with incomplete personal protective equipment use and adherence to biosafety precautions demonstrated no serological evidence of prior HPAI A(H5N1) virus infection.[112]

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