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Summary of Assessment of Public Health Risk to Canada Associated with Avian Influenza A(H7N9) Virus in China

The risk assessment is reviewed on a regular basis and updated as required.

21 April 2015

Risk Assessment

An outbreak of human infections with a new avian influenza A (H7N9) virus was first reported in China by the World Health Organization on April 1, 2013. On January 26, 2015, the first imported human case of avian influenza A (H7N9) from China was confirmed in Canada. A second case was confirmed on January 29, 2015. They are the first North Americans known to have been infected with this virus. The individuals were from British Columbia and travelled together to China. Neither required hospitalization and both have recovered. The public health risk posed by avian influenza A(H7N9) virus from China to Canada is considered low at this time.

Available information suggests that this virus does not have the ability to transmit easily among humans. Clusters that have been reported suggest that limited human-to-human transmission may occur where there was unprotected close contact with symptomatic cases, but no onward transmission has been detected.

There is still no evidence of sustained human-to-human transmission of avian influenza A(H7N9) virus. However, clusters suggest that limited human-to-human transmission may occur where there is close contact between cases and other people.

There is no indication that international spread has occurred, although when infected people from affected areas travel, their infection may be detected in another country. WHO continues to advise countries to move forward in strengthening influenza epidemiological and virological surveillance, reporting of human infections as applicable under the IHR (2005), and other national health preparedness actions.

Event Summary

An outbreak of human infections with a new avian influenza A (H7N9) virus was first reported in China by the World Health Organization on April 1, 2013. Cases have been reported in China from twelve Provinces (Anhui, Guangdong, Guangxi, Hebei, Henan, Hunan, Fujian, Jiangsu, Jiangxi, Jilin, Shandong, and Zhejiang), two Municipalities (Beijing and Shanghai) and in one autonomous region (Xinjiang Uyghur). In addition, travel-related cases have been reported in Malaysia, Taiwan, Hong Kong and most recently in Canada. Poultry and environmental samples have tested positive for avian influenza A(H7N9) in all above mentioned provinces and municipalities, except for Jilin and Beijing. Most human infections are believed to have occurred after exposure to infected poultry or contaminated environments.

As of April 21, 2015, the WHO has reported 651 confirmed human cases, including 225 deaths. For the latest updates on cases and deaths please visit WHO's Global Alert and Response websiteExternal Link.

Since October 2014, a third wave of human cases has been occurring. Cases have been reported in both men and women across a wide range of ages. Thus far, the three waves show a seasonal pattern, peaking in the winter months and sporadic cases during the summer. Atypical clinical presentation for influenza has not been reported.

The second wave had significantly larger amplitude than the first wave, both in terms of number of cases and geographically, suggesting that the virus became more widespread in its domestic bird reservoir. The age and sex distribution remained the same during the first two waves, occurring among middle aged or elderly males. The number of cases and deaths in this third wave to date is very similar to those in the second wave. However, potential data limitations means that caution must be exercised when interpreting these trends. The evidence to date does not support sustained human-to-human transmission although several small human clusters have been identified. The majority of cases reported since October 2013 are from the provinces of Zhejiang and Guangdong.

A rapid risk assessment published by the European Centre for Disease Prevention and Control on 26 February 2014 has identified that the most likely current scenario for China is that these outbreaks remain zoonotic outbreaks in which the virus is transmitted sporadically to humans in close contact with the animal reservoir, similar to the influenza A (H5N1) situation.

The animal reservoir(s), main exposures and routes of transmission to humans, and the distribution and prevalence of this virus among people and animals are currently under investigation; however, the WHO reports that human infection appears to be associated with exposure to live poultry or contaminated environments, including markets where live poultry is sold, for the following reasons:

  • Most human cases report a history of exposure to birds or live poultry markets (approximately 80%).
  • The virus in humans is genetically similar to that found in animals and the environment (live bird markets).
  • Targeted testing of poultry and environment in live poultry markets that are epidemiologically linked with human cases of avian influenza A(HN9) infection has revealed more positive results than testing in areas not linked with human cases.

Infection in health care workers is also of specific interest as infection in a healthcare worker has recently been identified. Investigation suggested possible exposure to poultry or contaminated environment as the likely source of infection, and no other associated human cases have been identified. Given the detection of several less severe cases through ILI surveillance, along with continued reporting of severe cases, continued vigilance is warrantedFootnote 1.

With an increasing number of cases being reported since the fall, some local jurisdictions have taken measures to mitigate the risk of infection by temporarily closing live poultry markets or implementing additional decontamination protocols. One study found that market closures were an effective control strategy in several regions during the first two waves and the effectiveness of the closures varied between regions7.

A scientific publication by the Infectious Diseases of Poverty indicates that it is necessary to regulate the poultry markets as long as poultry-to-poultry transmission is not well understoodFootnote 2. The Canadian Food and Inspection Agency (CFIA) published its "Preliminary Assessment of the Risk to Canadian Animals from the Novel H7N9 Influenza Virus Detected in China" and highlighted that: evidence to date strongly indicates that the novel H7N9 in poultry does not differ from other Influenza A viruses common in the animal population at the global level; this novel H7N9 virus is of avian origin and does not cause any severe clinical signs in poultry; and the risk to Canadian animals from the novel H7N9 influenza virus detected in China is considered to range from negligible to very low. The Food and Agriculture Organization of the United Nations (FAO) published an updated qualitative risk assessment on January 20, 2014. The FAO has identified there is an increased likelihood of avian influenza A(H7N9) spreading from an infected farm to an uninfected farm within affected areas of China, and from a known affected area to a "moderate to high-risk" area through live bird markets and live poultry movementsFootnote 6.

No vaccine is currently publicly available for this subtype of the H7N9 influenza virus; although several candidate vaccines are undergoing clinical trials. WHO has recommended that an A/Anhui/1/2013-like virus be used for the development of A(H7N9) vaccines for pandemic preparedness purposes. There are currently no recommendations on the large-scale manufacture of avian influenza A(H7N9) vaccineFootnote 3.

Laboratory testing has confirmed that the avian influenza A(H7N9) virus is susceptible to the neuraminidase inhibitors oseltamivir and zanamivir, two antiviral medications that are available in the National Antiviral Stockpile and National Emergency Stockpile System should they be needed to treat Canadians. WHO has issued WHO has issued guidance on the use of post-exposure antiviral chemoprophylaxis for avian influenza A(H7N9)External Link (PDF Document).

The Agency's National Microbiology Laboratory (NML) has developed diagnostic assays (tests) allowing NML to rapidly detect the novel avian influenza A(H7N9) virus. These assays have been shared with provincial/territorial colleagues allowing provinces to do their own testing should it be required.

Virus Characteristics

Sequencing of the avian influenza A(H7N9) virus by the World Health Organization (WHO) Chinese National Influenza Centre in Beijing revealed HA and NA genes from avian influenza A(H7N9) and remaining genes from A(H9N2), identifying this virus as a novel reassortant virus with all genes related to genes from Eurasian influenza A viruses from wild birds and poultry. Scientific publications in the LancetFootnote 4 and New England Journal of MedicineFootnote 6 suggest that poultry is a likely source of infection. This novel avian influenza A(H7N9) virus does not appear to cause severe illness in birds. This is different from previously identified and reported avian influenza A(H7N9) viruses in birds. Mutations in H7N9 strains have been identified that could favour high affinity interaction with human receptors in the upper respiratory tractFootnote 5 however, there has been no evidence of sustained human-to-human transmission. Presently, this avian influenza A(H7N9) virus is considered a Foreign Animal Disease (FAD) agent as there may be consequences if this pathogen were to circulate in avian populations in Canada.

Recommendations for Canada


Health care professionals are encouraged to maintain vigilance for cases of avian influenza A(H7N9) infection and notify the appropriate local Public Health Unit in their jurisdiction of any persons under investigation. The national interim case definition for avian influenza A(H7N9) is to be used for the surveillance of avian influenza A(H7N9). For guidance on surveillance objectives and activities, please refer to the interim national surveillance guidelines for avian influenza A(H7N9).

Provinces and Territories are asked to report confirmed cases of avian influenza A(H7N9) infection to the Public Health Agency of Canada using the Emerging Pathogens and Severe Acute Respiratory Infection (SARI) Case Report Form.

Travel Advisory

A travel health advisory is posted on the Agency's website. It does not recommend any restrictions on travel but encourages travellers to practice special precautions.

Infection Control

The Agency provides recommendations for infection prevention and control measures for patients presenting to hospitals, doctors offices and other clinics with suspected or confirmed infection with the avian influenza A(H7N9) virus in its Interim Guidance - Infection Prevention and Control Guidance for Acute Care Settings document. This guidance will be updated as new evidence becomes available.


Based on the clinical presentation of severe respiratory illness and death in humans, the potential for this virus to be a pandemic agent, and that the virus is currently considered a foreign animal disease agent, this avian influenza A(H7N9) virus is classified as a Risk Group 3 human and animal pathogen requiring Containment Level 3 for all proliferative in vitro or in vivo activities. Non-proliferative diagnostic/clinical activities can be conducted at Containment Level 2 with additional requirements. In the event of a non-negative human sample, it is strongly recommended that the work with the sample be stopped and the sample be transferred to the National Microbiology Laboratory (NML). In the event that a veterinary diagnostic laboratory detects a non-negative sample, the work is to be stopped and the sample be transferred to the National Centre for Foreign Animal Disease (NCFAD) as per the policy in the Foreign Animal Disease Diagnostic Laboratory Containment Standard. The biosafety advisory can be found on the Agency website.

Footnote 1
World Health Organization. WHO Risk assessment - Human infections with avian influenza A(H7N9) virus 21 January 2014. RiskAssessment_H7N9_21Jan14.pdf.
Footnote 2
Benyun S, Shang X, Guo-Jing Y, Xiao-Nong Z, Jiming L. 2013. Inferring the potential risks of H7N9 infection by spatiotemporally characterizing bird migration and poultry distribution in eastern China. BMC Infectious Diseases of Poverty 2013, 2:8 doi:10.1186/2049-9957-2-8
Footnote 3
World Health Organization. WHO recommendation on influenza A(H7N9) vaccine virus 26 September 2013. 201309_h7n9_recommendation.pdf
Footnote 4
Chen Y, Liang W, Yang S, et al. 2013. Human infections with the emerging avian influenza A H7N9 virus from wet market poultry: clinical analysis and characterisation of viral genome. Lancet. doi:pii: S0140-6736(13)60903-4. [Epub ahead of print]
Footnote 5
Qun Li, M.D., Lei Zhou, M.D. et al, 2013. Preliminary Report: Epidemiology of the Avian Influenza A (H7N9) Outbreak in China. The New England and Journal l of Medicine: April 24, 2013, at DOI: 10.1056/NEJMoa1304617
Footnote 6
Food and Agriculture Organization. Addressing avian influenza A(H7N9). Qualitative risk assessment update. January 2014.
Footnote 7
Kucharski AJ, Mills HL, Donnelly CA, Riley S. Transmission potential of influenza A(H7N9) virus, China, 2013-2014. Emerg Infect Dis. 2015 May [April 7, 2015].