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The Expert Group set up to investigate the deaths of three children with acute febrile illnesses in recent months released its report today (April 18).
The Expert Group, chaired by Professor KY Yuen, Head of Department of Microbiology at the University of Hong Kong, was appointed by the Government on March 12 to investigate the role of influenza in these deaths and to make recommendations to minimise similar incidents in future.
Members of the expert group included Professor Paul Chan from the Chinese University of Hong Kong; Dr Chow Chun-bong, Consultant, Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital; Dr Ng Wai-fu, Consultant in-charge, Department of Pathology Service, Yan Chai Hospital & Princess Margaret Hospital; Dr Sidney Tam, Head/Consultant, Division of Clinical Biochemistry, Queen Mary Hospital; and Dr Hau Kong-lung, Consultant Forensic Pathologist in charge, Department of Health.
Speaking at a press conference today, Professor Yuen said influenza was directly related to the death of one child, the seven-year-old boy who passed away in Tuen Mun Hospital on March 11 with acute necrotising encephalopathy due to influenza A H1N1.
As for the three-year-old girl who died in Tuen Mun Hospital on March 1, Professor Yuen said her death was likely to be related to acute cardiac arrhythmia produced by an underlying structural variation in her coronary artery and some genetic polymorphisms which predisposed her to cardiac arrhythmia or metabolic dysfunction. The possible triggering factors included the stress of influenza A H3N2 virus infection and the use of multiple drugs of similar nature.
"However, the relative contribution of these factors to her death is not certain," Professor Yuen said.
Professor Yuen pointed out that the H1N1 virus found in the seven-year-old boy had the same genetic makeup as the circulating H1N1 (Brisbane) strain in Hong Kong. Also, the H3N2 virus found in the body of the three-year-old girl indicated the same genetic composition as the circulating H3N2 (Brisbane) strain.
"Both strains have been circulating in different parts of the world during the current flu season and the two children did not die from a new virus that is more virulent than the circulating strains in the region," he said.
Professor Yuen said the cause of death of the two-year-old boy in Prince of Wales Hospital on February 26 was acute myocarditis of unknown microbial aetiology though his elder sister had suffered from influenza B infection.
"No influenza or other virus could be found in his body despite extensive investigations," he noted.
The Expert Group, based on the epidemiological, clinical, toxicological and microbiological findings, made a series of recommendations on how to reduce a similar occurrence in future, including:
Public health recommendations
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1) In view of the high rate of influenza-related hospitalisation and neurological complications in children, a review should be conducted in respect of extending the recommended age range of childhood vaccination for influenza. This will also benefit the elderly indirectly by the herd immunity. Further recommendations should be left to the Scientific Committee on Vaccine Preventable Diseases of the Centre for Health Protection.
2) Post-exposure antiviral prophylaxis or early treatment can be considered for children at risk on a case-by-case basis during school outbreaks with related deaths or when increased viral virulence is suspected. This should be evaluated together with the updated information on the adverse effects of antiviral.
3) Closure of an individual school during outbreaks may be considered taking reference from (but not solely dictated by) certain indicators, such as: when the sick leave rate is 10% or more, the hospitalisation rate is more than 1%, there are two or more ICU admissions, or any death in the school due to influenza in otherwise healthy children.
4) Children with acute febrile illness should not attend school until 48 hours post-defervescence. Rest is important for the recovery process and the immune system of the child.
5) During outbreaks or influenza seasons, the warmth/coolness of classrooms should be maintained without compromising the indoor ventilation rate of more than six air-changes per hour. This can be achieved by simply keeping all windows and doors of the classroom open.
6) Direct drinking of water from drinking fountains by young children at schools should be discouraged because backwashing of oral and nasal secretions onto the water outlets may cause cross-infection.
Clinical recommendations
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1) Subtle clinical features such as repeated visits to doctors or narrow pulse pressure should alert the attending clinicians to consider hospital admissions or more thorough and vigorous investigations for serious complications.
2) The main purpose of a visit to a doctor during an influenza-like illness is for the exclusion of a more serious illness or complications which requires further investigation and immediate treatment. Except in special circumstances, the culture of polypharmacy of drugs of similar nature can be dangerous and should be discouraged.
3) For better protection of patients, doctors must know the generic names instead of or in addition to the proprietary names of the medications so as to avoid prescription of multiple drugs with similar actions unwittingly in the symptomatic management of influenza infection.
4) The dosage of drugs should always be tailored according to the professionally accepted recommendations.
5) Current medications should be brought to the attention of the new doctors taking over the management so that they can be aware of the potential drug induced complications or serious drug interactions.
6) For better patient protection, the private and public health service database of all patients should be linked. Patients should have 24-hour access to their diagnoses and treatments, which should also be made accessible to authorised health personnel upon consent of the patients or their guardians.
Recommendations on pathological surveillance
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1) A surveillance of unexplained deaths or critical illness due to possible infectious causes should be performed by investigating all acute deaths in previously healthy people less than age 50 who died of or were hospitalised with a life-threatening illness with hallmarks of an infectious aetiology for which no cause was identified.
2) Result of toxicological analysis is often difficult to interpret in postmortem samples due to drug redistribution and other postmortem changes. Standard operating procedures (SOP) should therefore be established for proper collection of peri-mortem biological specimens (e.g., blood, urine, tissues or other bodily fluids) at the AED in death of unknown cause. SOP should also be established for collection of appropriate biological specimens (e.g., blood, urine, other bodily fluids) at the AED from patients in critical conditions where unknown infectious disease, intoxication or esoteric metabolic disorder is suspected. The sample collection should be performed, inasmuch as circumstance allows, prior to therapeutic interventions as the latter may mask or obscure the underlying aetiology.
In response to the findings and recommendations, the Controller of the Centre for Health Protection (CHP) of the Department of Health, Dr Thomas Tsang, expressed his gratitude to the Expert Group for its dedicated efforts in completing the investigation and thanked them for their highly valuable recommendations.
Dr Tsang also expressed his condolences to the families of the three children and thanked them for their co-operation in assisting the Expert Group's investigation.
Taking reference from the Expert Group's public health recommendations, CHP has initiated the following measures:
- The findings and recommendations of the Expert Group are being considered by the Scientific Committee on Vaccine Preventable Diseases under CHP in reviewing the recommended age range for influenza vaccination in children.
- CHP is taking reference from the Expert Group's recommendations in advising closure of individual schools during outbreaks.
- CHP and Education Bureau have promulgated clear guidelines to schools advising parents not to take children to attend school until 48 hours after fever subsides.
- CHP is liaising with Education Bureau to reinforce advice on maintaining good ventilation and proper use of drinking fountains among young children in schools.
"We will further study the report findings and recommendations in detail and take additional and appropriate follow up actions," Dr Tsang said.
The executive summary and recommendations of the Expert Group report will be posted on the CHP webpage (www.chp.gov.hk).
Ends/Friday, April 18, 2008
Issued at HKT 18:36
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