Yale - Tulane ESF-8 MOC Brief Special Report - A(H7N9) 15 April 2013


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In light of the H7N9 , the Yale-Tulane ESF #8 Planning and Response Program has produced a special report on A(H7N9).The Yale-Tulane ESF #8 Program is a multi-disciplinary, multi-center, graduate-level, program designed to produce ESF #8 planners and responders with standardized skill sets that are consistent with evolving public policy, technologies, and best practices. The group that produced this summary and analysis of the current situation are graduate students from Yale and Tulane Universities. It was compiled entirely from open source materials. Please feel free to forward the report to anyone who might be interested.

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  • While the novel A(H7N9) virus has been detected in birds and environmental specimens at a bird markets in Shanghai and the other affected provinces, the source of infection in most of the cases still remains to be determined [6 ]. It is equally unclear how the virus is introduced into the markets. Nevertheless, China has stepped up vigilance and intensified human and animal surveillance [7]. It has also implemented public health measures that include the closure of some live poultry and bird markets and culling of birds [8]. 
  • While the novel A(H7N9) virus has been detected in birds and environmental specimens at a bird markets in Shanghai and the other affected provinces, the source of infection in most of the cases still remains to be determined [6 ]. It is equally unclear how the virus is introduced into the markets. Nevertheless, China has stepped up vigilance and intensified human and animal surveillance [7]. It has also implemented public health measures that include the closure of some live poultry and bird markets and culling of birds [8]. 
  • Yale - Tulane ESF-8 MOC Brief Special Report - A(H7N9) 15 April 2013

    1. 1. BACKGROUNDSITUATIONAS OF 1600 HRS EDT15 APRIL 2013RISK ASSESSMENTAVIAN INFLUENZAHUMAN CASESCHINESE GOVERNMENT ORGANIZATIONS Ministry of Health of the People’s Republic of China Chinese Center for Disease Control and Prevention Hong Kong Department of Health | Centre for Health Protection National Health and Family Planning CommissionINTERNATIONAL ORGANIZATIONSFAOOIEWHO World Health Organization Western Pacific Region Disease Outbreak News Human infection with influenza A(H7N9) virus Global Initiative on Sharing All Influenza Data (GISAID)US GOVERNMENTCDC – Health InfoEUROPEANUNIONECDCPORTALS, BLOGS, AND RESOURCES Avian Flu Diary CIDRAP FluTrackers.com Flu Wiki Health Map ProMed Mail Virology Down UnderNEW SOURCES People’s Daily Online – China High Alert H7N9 Forbes AlertNet Reuters NY TimesYALE- TULANE ESF-8 SPECIAL REPORTA(H7N9)SCREENING PATIENTS RETURNINGFROM CHINAMAPTIPS FOR THOSE VISITING CHINARESPONSEAS OF 15 APRIL 2013CONFIRMED DEAD64 14 ECONOMIC IMPACTSCDC to update clinicians, healthdepartments on #H7N9 flu. Call inApril 18, 2PM ET:http://goo.gl/DLm1J
    2. 2. BACKGROUNDWhile the novel A(H7N9) virus has been detected in birds andenvironmental specimens at a bird markets in Shanghai and the otheraffected provinces, the source of infection in most of the cases stillremains to be determinedIt is equally unclear how the virus was introduced into the markets.China has intensified human and animal surveillance. It has alsoimplemented public health measures that include the culling of birds andthe closure of some live poultry and bird marketsSOURCE: Global Alert Response, (1 APRIL 2013)http://www.who.int/csr/don/2013_04_01/en/Flu.Gov (April 2013) Avian Influenza A (H7N9) Virushttp://www.flu.gov/about_the_flu/h7n9/index.html#On 31 March 2013, the World Health Organization (WHO) was notified byChina’s Health and Family Planning Commission of three cases of humaninfection with the influenza A(H7N9) virus•Since then, additional cases have been reported. Most reported cases havesevere respiratory illness and, in some cases, have died.•At this time, no cases of H7N9 outside of China have been reported. Thenew H7N9 virus has not been detected in people or birds in the UnitedStates.•This new H7N9 virus is an avian (bird) influenza (flu) virus. Humaninfections with avian influenza (AI, or “bird flu”) are rare, but have occurredin the past, most commonly after exposure to infected poultry.• This is the first time that this bird flu subtype (H7N9) has been found inpeople. This virus is very different from other H7N9 viruses previouslyfound in birds.•Many of the human cases of H7N9 are reported to have had contact withpoultry. However, some cases reportedly have not had such contact.•Close contacts of confirmed H7N9 patients are being followed to see if anyhuman-to-human spread of H7N9 has occurred. No sustained person-to-person spread of the H7N9 virus has been confirmed at this time.• There is no licensed vaccine available at this time..A man infected with H7N9 bird flu receives treatment at anintensive care unit in a hospital in Kaifeng, Henan province, onSunday.( Li Bo / Xinhua )
    3. 3. CASE UPDATES• The National Health and Family Planning Commission continues tonotify WHO as there are are additional laboratory-confirmed cases ofhuman infection with influenza A(H7N9) virus.• Cases have been confirmed in the following provinces andmunicipalities: Shanghai, Beijing Jiangsu, Anhui, Henan and Zhejiang.All locations are in Eastern and Northern China.• The age of confirmed cases ranges from 4-87 years old.• Cases presented with respiratory tract infection with progression tosevere pneumonia and breathing difficulties. More than 1,000 closecontacts of the identified cases are being closely monitored.• Two confirmed cases have been associated with possible familyclusters. Close contacts of confirmed cases and health care workerscaring for cases have been monitored for infection. So far, among thecontacts who have been tested by polymerase chain reaction, nonehas been shown to have infection.SITUATIONChinese Centers for Disease Control – H7N9 Update GISAID H7N9 virus sequencing Global Concerns Regarding Novel Influenza A (H7N9) Virus InfectionsCenters for Disease Control and Prevention – Travelers’ Health World Health Organization Global Alert and Response Virology Down UnderChinese Centers for Disease Control and Prevention H7N9 Information WHO H7N9 Risk AssessmentAs of 15 April 2013 there have been a total of 64confirmed cases and 14 deaths.On 15 April, Beijing Municipal Health Bureau reported that a four-year-old boy,who was tested positive for H7N9 flu virus, was asymptomatic.
    4. 4. SITUATIONVIRUS CHARACTERIZATION• This is the first time human infection with this influenzasubtype, avian influenza A(H7N9) virus, has been detected.• The sequences of the first three viruses were posted to GISAIDby China and are publicly available.ANTIVIRAL DRUGS: So far, all three viruses seem to besusceptible to the influenza antiviral drugs oseltamivir andzanamivir, but they are resistant to the amantanesVACCINE: There is no licensed H7N9 vaccine currently available,but pharmaceutical manufacturers are currently using syntheticbiology techniques to develop a candidate vaccine strain.The schematic above (provided by CDC) shows the structure of an influenza virus particle.There are two major proteins found on the virus surface, hemagglutinin (that is the ”H” when thevirus type is designated) and neuraminidase (the “N”)GENETIC CHARACTERISTICS•The novel H7N9 viruses have genetic characteristics that are ofconcern.•The hemagglutinin (HA) sequence data suggest that these H7N9viruses are a low-pathogenic avian influenza A virus and thatinfection of wild birds and domestic poultry would therefore resultin asymptomatic or mild avian disease, potentially leading to a“silent” widespread epizootic in China and neighboring countries.• If H7N9 virus infection is primarily zoonotic, as reports currentlysuggest, transmission is expected to occur through exposure toclinically normal but infected poultry, in contrast to HPAI H5N1 virusinfection, which typically causes rapid death in infected chickens.•The gene sequences also indicate that these viruses may be betteradapted than other avian influenza viruses to infecting mammals.•Ongoing surveillance is crucial to assessing the emergence andprevalence of H7N9 viruses resistant to available antivirals.
    5. 5. REPONSE ACTIVITIESCHINESE GOVERNMENT ACTIVITIES• Chinese government notifies the World Health Organization ofthe emergence of an A(H7N9)• Chinese health authorities are conducting investigations to learnthe source of the infections with this virus• Chinese scientists first sequence the viral genome and identifiedthe origin of this new virus.• The Chinese government has instituted enhanced surveillance,strengthened laboratory utilization, and training of health careprofessionals for detection, reporting, and treatment.• All influenza network laboratories in the 31 provincial regions onChinas mainland are now capable of testing for the H7N9 birdflu virusUS GOVERNMENT ACTIVITIES5 April:• CDC holds a telebriefing on H7N9 Influenza Cases• CDC issues a Health Advisory, Human Infections with NovelInfluenza A (H7N9).8 April:• The US Centers for Disease Control and Prevention (CDC)activates its Emergency Operations Center (EOC) in Atlanta atLevel 2 to support the response to the H7N9 influenzaoutbreak in China, CDC officials said in an e-mailed statementtoday.• CDC post a Travel Notice about avian influenza A (H7N9) onwww.cdc.gov/travel11 April:• China provides US CDC with virus sample for vaccinedevelopment
    6. 6. NUMBER OF DEATHS / NUMBER OF CONFIRMED CASESNO EVIDENCE OF H7N9 TRANSMISSION FROMPERSON-TO-PERSON1,2,3However, this is still a future possibility:• Every time the virus encounters and infects a newhuman host, it has the opportunity to mutate.2• The haemagglutinin (H) surface protein on the virushas shown mutations that precede a change inbinding preference from bird to human cells.2,4• A PB2 protein substitution is also indicative ofmammalian adaptation of the virus4ALL CONFIRMED CASES AND DEATHS WITHIN CHINA1• Cases in 29 prefectures/districts across 6 provincesCases Type Most Recent Total1Deaths 14Laboratory-ConfirmedCases64Sources: 1. China CDC 2. www.Nature.com/news 3. South China Morning Post 4. www.NEJM.orgNote: All case and death totals are as of 8pm EST, April 14, 2013H7N9 HAS NEVER BEFORE BEEN DETECTED INHUMANS4• Rapid diagnostic tests are currently unavailable4• All age groups expected to be susceptible4Place1 Cases1 Deaths1 Place1 Cases1 Deaths1Beijing 2 0 Zhejiang 16 2Shanghai 24 9 Anhui 3 1Jiangsu 17 2 Henan 2 0
    7. 7. NUMBER OF DEATHS / NUMBER OF CONFIRMED CASESTotal number ofconfirmed humancases A(H7N9)60Total number ofdeaths attributedA(H7N9)13Current CaseFatality Rate22%Average time fromillness onset to firstconfirmation ofH7N9 (days):10 daysAverage age of theH7N9-confirmedcases59 yearsMedian age of theH7N9 confirmedcases64 yearsModal age of theH7N9 confirmedcases74 yearsAverage age ofdeceased62 yearsMales 71% of thecases 71%of thefatalitiesFemales 29%of thecases 71%of thefatalitiesSOURCE: Virology Down Under
    8. 8. 924021321721602DISTRIBUTION OF CASES GEOGRAPHICALLYTotal numberof confirmedcasesTotal numberof deathsSource: China CDC http://www.chinacdc.cn/en/research_5311/H7N9update/201304/t20130414_79862.html
    9. 9. RISK ASSESSMENTGENERAL INFORMATION: At this time, there are still gaps in information and evidence available. Investigations into possible sources of infection and reservoirs of the virus are ongoing. This is the first time that human infection with influenza A(H7N9) virus has been identified and the first time that human infection with a low pathogenicavian influenza A virus has been associated with a fatal outcome. For precautionary reasons, those working in or visiting China should avoid visiting live bird and animal markets and direct contact with bird and animalfeces, untreated bird feathers, and other animal and bird waste.TWO RISK ASSESSMENTS HAVE BEEN PUBLISHED:European Centre for Disease Prevention and Control (12 April 2013)http://www.ecdc.europa.eu/en/publications/Publications/influenza-A(H7N9)-China-rapid-risk-assessment-4-april-2013.pdfWorld Health Organization (13 April 2013):http://www.who.int/influenza/human_animal_interface/influenza_h7n9/RiskAssessment_H7N9_13Apr13.pdf• There is no evidence of sustained human-to-human transmission. However the two possible family clusters suggest that limited human-to-humantransmission may occur where there is close contact between cases and other individuals, as occurs in families and, potentially, healthcaresettings.• At this time, there is no information to indicate international spread of this virus. However, it is possible that an infected person, who may or may nothave symptoms, could travel to another country. If the virus cannot sustain human-to-human transmission, as appears to be the current situation,then extensive community spread is unlikely.• WHO does not advise special screening at points of entry with regard to this event, nor does it recommend that any travel or trade restrictions beapplied.
    10. 10. RISK OF HUMAN TO HUMAN TRANSMISSION Insufficient evidence to determine risk of A(H7N9) human tohuman transmission. Risk of healthcare-associated transmission when caring forinfected patients not yet determined Infective period for A(H7N9) cases not known but patients likely toexcrete the virus in body fluidsRISK OF FURTHER CASES IN CHINA Most human cases of H7N9 likely due to animal exposure Further cases are expectedRISK OF INTERNATIONAL SPREAD Risk of international spread via humans currently low As virus cannot sustain human-to-human transmission, extensivespread unlikely regardless of infected travelers WHO does not advise special screening at points of entry withregard to this event or any travel restrictions No cases have been reported outside of ChinaOTHER MODES OF TRANSMISSION No epidemiological evidence of transmission to humans throughthe consumption of food Low or no risk of transmission through blood transfusion ororgan/tissue donations Importation through food and agricultural products from Chinaunlikely due to importation restrictions Risk of spread through migratory birds unknown Virus has not been detected in wild birds at this timeRISK ASSESSMENTEuropean Centre for Disease Prevention and Control (12 April 2013)http://www.ecdc.europa.eu/en/publications/Publications/influenza-A(H7N9)-China-rapid-risk-assessment-4-april-2013.pdfWorld Health Organization (13 April 2013):http://www.who.int/influenza/human_animal_interface/influenza_h7n9/RiskAssessment_H7N9_13Apr13.pdf
    11. 11. AVIAN INFLUENZAA(H7N9)WHAT IS AVIAN INFLUENZA (AI)?WHAT IS INFLUENZA A(H7N9)?WHAT IS THE SOURCE OF INFLUENZA A(H7N9)?SOURCE: OIE – Questions and Answers on Influenza A(H7N9)PRESENT SITUATION IN CHINA•To date, a total of 60 cases have beenlaboratory confirmed with influenzaA(H7N9) virus in mainland China,including 14 deaths.•The China Animal Disease ControlCentre and the country’s animal healthservices, including the OIE ReferenceLaboratory in Harbin, are stillinvestigating animal sources andpossible reservoirs of the influenzavirus A(H7N9).Chinese health workers collect bags ofdead chickens at the Huhai wholesalemarket on April 5. China on high alertover bird flu In Shanghai, more than100,000 live birds have been killed inthe past week at live-poultry marketsacross the city in an effort to containthe problem - CNNThe first human cases of type Ainfluenza virus of the strain H7N9.was found in March 13, 2013. Thisstrain of virus usually infects birds,and the report was followed byreinforced surveillance in birdpopulations in China.The virus has been found in a pigeonin a market in Shanghai. It is not yetknown how persons becameinfected. The possibility of animal-to-human transmission is beinginvestigated, as is the possibility ofperson-to-person transmission.Wild birds can normally carry avianinfluenza viruses in their respiratoryor intestinal tracts but they do notcommonly get sick. They havehistorically been reservoirs ofinfluenza virusesAvian influenza (AI) is aninfectious viral disease ofbirds (especially wild waterfowl such as ducks andgeese), often causing noapparent signs of illness. AIviruses can sometimesspread to domestic poultryand cause large-scaleoutbreaks of serious disease.Outbreaks of AI in poultry often raiseglobal public health concerns due totheir effect on poultry populations,their potential to cause seriousdisease in people, and their pandemicpotential.At this time there is no evidence ofongoing human-to-humantransmission.Influenza A H7N9 viruses are a group ofinfluenza viruses that normally circulateamong birds. The influenza A(H7N9) virus isone subgroup among the larger group of H7viruses. Although some H7 viruses (H7N2,H7N3 and H7N7) have occasionally beenfound to infect humans, no humaninfections with H7N9 viruses have beenreported until recent reports from China.Influenza - or, as it is often known, flu - isa large family of different viruses (morethan 70 major types), some of whichaffect humans and many of which affectother animals, especially birds.
    12. 12. AVIAN INFLUENZAA(H7N9)HOW IS INFLUENZA A(H7N9) TRANSMITTED ANDSPREAD AMONG BIRDS?WHAT ARE THE REPORTING REQUIREMENTS FORINFLUENZA A(H7N9)?HAVE WILD BIRDS BEEN IDENTIFIED AS A CARRIEROF THE INFLUENZA A(H7N9) VIRUS?Map of outbreaklocations. SOURCE:OIEThus far, most patients withthis infection have hadsevere pneumonia.Symptoms include fever,cough and shortness ofbreath. However,information is still limitedabout the full spectrum ofdisease that infection withinfluenza A(H7N9) virusmight cause.OIE Terrestrial Animal HealthCode reporting guidelinesConfirmed Case: A patient with novelinfluenza A (H7N9) virus infection that isconfirmed by CDC’s Influenza Laboratory or aCDC certified public health laboratory usingmethods agreed upon by CDC and CSTE.Probable Case: A patient with illnesscompatible with influenza for whomlaboratory diagnostic testing is positive forinfluenza A, negative for H1, negative forH1pdm09, and negative for H3 by real-timereverse transcriptase polymerase chainreaction (RT-PCR), and thereforeunsubtypeable.An investigation by Chinese authorities is ongoing.H7N9 viruses have been detected in poultry in thesame area where human infections have occurred.Many of the human cases of H7N9 are reported tohave had contact with poultry. However some casesreportedly have not had such contact. Close contactsof confirmed H7N9 patients are being followed tosee if any human-to-human spread of H7N9 mighthave occurred.All the patients had preexisting medical conditions,and two had a history of direct contact with poultry.Since April 4, it has beenreported that H7N9 virusessimilar to those isolated fromthe three patients describedhere have been isolated frompigeons and chickens,indicating that the novel H7N9viruses might currently becirculating in poultry.All AI viruses can be transmittedamong birds through directcontact with secretions frominfected birds, especially feces orthrough contaminated feed,water, equipment, and humanclothing.Several factors can contribute tothe spread of all AI virusesincluding: the movements ofpeople and goods, marketingpractices (live bird markets),farming practices and thepresence of the viruses inmigratory wild birds.We do not yet know enough about theseinfections to determine whether there is asignificant risk of community spread. Thispossibility is the subject of epidemiologicalinvestigations that are now taking place.Does this influenza virus pose a pandemicthreat?Any animal influenza virus that develops theability to infect people is a theoretical risk tocause a pandemic. However, whether theinfluenza A(H7N9) virus could actually cause apandemic is unknown. Other animal influenzaviruses that have been found to occasionallyinfect people have not gone on to cause apandemic.
    13. 13. ECONOMIC IMPACTSCURRENT SITUATION• China exports 1821.9 Hundred Million dollars of goods per month.• China produces 12.1 million metric tons of broiler meat.• SARS caused year-over-year growth to fall to 7.9% from 10.8% in Q1 2003--H7N9 may cause a similar drop.TRADE BANS• Vietnam has banned Chinese poultry imports.• Shanghai’s, Huhai’s, Hangzhou’s, Nanjin’s, and several other poultrymarkets have been closed.• More bans may proliferate.TRAVEL• No travel bans are in place.• Japanese airports are on alert for arriving travelers from China who exhibitflu-like symptoms.FOOD SECURITY• Chicken meat is a popular source of protein among poor workers.• In order to decrease the risk of H7N9 spread many birds were slaughteredand will continue to be slaughtered. This could lead to food shortages anda lack of protein, especially for the poor. Consumers are also avoidingpoultry and egg, despite authorities assuring that it is safe to eat ifproperly cooked.MARKET REACTION• Soybeans and poultry shares are down on the Chinese market, butpharmaceutical stocks are up, as well as the sales of medicinal herbs.Overall the Shanghai index is down .7%, the Hang Seng index 2.7%, andBloomberg US-China Equity Index 1.8% due to fears of reduced economicgrowth The market has reacted similarly to travel companies, hotels,educational services, retail, and consumer staples due to beliefs thatpeople will avoid congregating and traveling.• Sales of chicken are down, while sales of masks and hand sanitizer are up.http://www.thepoultrysite.com/http://www.grains.org/index.php/2012-04-30-15-22-26/4162-h7n9-affects-chinese-poultry-markethttp://www.chinaeconomicreview.com/big-bad-birdhttp://www.guardian.co.uk/world/2013/apr/05/bird-flu-shanghai-poultry-market-cullRAMIFICATIONS: If H7N9 continues to spread or simply generateslarge amount of China’s recovery from the current global economicsituation could be retarded.MITIGATION: The WHO’s measured response to the disease hasprevented market panic or intense travel fears. Continuedconsideration of economic ramifications before issuing alerts will helpto minimize the amount of economic losses incurred.
    14. 14. OVERVIEWWhat is H7N9 virus? The virus appears to be a reassortment of three avianinfluenza viruses.How does H7N9 flu spread? Thus far, there is no evidence of human-to-human transmission. Some affected patient had exposures to poultry beforefalling ill. There is concern that H7N9 does not cause severe illness in birds andhence can potentially spread undetected from poultry to sporadic humancases.What are the symptoms? Predominant presenting symptoms have beensevere respiratory tract infections which progressed to pneumonia.SCREENINGKEY POINTSH7N9 is a new avian flu virus.Rare but serious human cases have occurredin China. So far, there is no evidence ofhuman-to-human transmission.References: (picture) www.abcnew.com, www.upmc-biosecurity.org, www.uptodate.com,http://emergency.cdc.gov/HAN/han00344.asp, http://www.cdc.gov/flu/avianflu/guidance-labtesting.htmWho should be tested ? Patients with flu symptoms and the followingexposure criteria:1. Recent travel to countries with human H7N9 cases, especially if therewas close contact with animals (e.g. wild birds, poultry or pigs) orwhere H7N9 viruses are known to be circulating in animals. Thus far,China is the only country with recent reported human cases.2. Recent contact with confirmed human H7N9 casesInformation on incubation period is incomplete but other avianinfluenza had incubation period ranging 3-9 days.Use Standard Precautions plus Droplet, Contact,and Airborne Precautions, including eye protectionuntil more is known about the transmissioncharacteristics.Commercial rapid influenza diagnostic tests may not detect avian or variant Aviruses. Hence a negative test does not exclude H7N9 infection.Send a nasopharyngeal swab or aspirate placed in viral transport medium tostate or local health department. Currently, all confirmatory testing for H7N9will be done by CDC.TREATMENTINFECTION CONTROLDo not base treatment decision solely on the result of a negative rapidinfluenza diagnostic test result.For patients in following categories, start empiric treatment with oraloseltamivir or inhaled zanamivir as soon as possible without waiting forlaboratory confirmation:1.Patients hospitalized with suspected influenza, including H7N9 cases2.High risk persons (age <5 or ≥65, certain underlying medicalconditions)Antiviral treatment is most effective if started as soon as possible afterthe onset of influenza illness. But treatment in moderate, severe, orprogressive disease that began after 48 hours may still have somebenefit.DIAGNOSTIC TESTSFACT SHEET: AVIAN INFLUENZA A (H7N9) VIRUSSCREENING PATIENTS RETURNING FROM CHINA
    15. 15. FACT SHEET: AVIAN INFLUENZA A (H7N9) VIRUSTIPS FOR THOSE VISITING CHINAOVERVIEWWhat is H7N9 flu? It is a contagious disease in humans and other animals thatcan sometimes lead to serious illness and death.How does H7N9 flu spread? An animal with H7N9 flu can give it to anotheranimal or human through feces, saliva, or nasal secretions. For now, there isno evidence of human to human transmission.What are the symptoms? Some of the following: fever, cough, sore throat,runny nose, body aches, headaches, chills, fatigue.PREVENTIONKEY POINTSH7N9 is a new bird flu virus.Rare but serious human cases have occurredin China. So far, there is no evidence ofhuman-to-human transmission.References: (picture) http://www.ottawacitizen.comhttp://www.cdc.gov/flu/avianflu/h7n9-virus.htm,http://www.who.int/csr/don/2013_04_10/en/http://wwwnc.cdc.gov/travel/notices/watch/avian-flu-h7n9-china.htmDo not touch birds or other animals.Do not touch animals whether they are alive or dead.Avoid live bird or poultry markets.Avoid other markets or farms with animals (wet markets).Eat food that is fully cooked.Eat meat and poultry that is fully cooked (not pink) and served hot.Eat hard-cooked eggs (not runny).Don’t eat or drink dishes that include blood from any animal.Don’t eat food from street vendors.Practice hygiene and cleanliness:–Wash your hands often.–If soap and water aren’t available, cleanyour hands with hand sanitizer containingat least 60% alcohol.– Don’t touch your eyes, nose, or mouth. If you need to touch your face,make sure your hands are clean.– Cover your mouth and nose with a tissue or your sleeve (not yourhands) when coughing or sneezing.– Try to avoid close contact, such as kissing, hugging or sharing eatingutensils or cups, with people who are sick.IF YOU BECOME ILL….See a doctor if you become sick during or after travel to China.‒ See a doctor right away if you become sick with fever, coughing, orshortness of breath.‒ If you get sick while you are still in China, visit the US Department of Statewebsite to find a list of local doctors and hospitals. Many foreign hospitalsand clinics are accredited by the Joint Commission International. A list ofaccredited facilities is available at their website(www.jointcommissioninternational.org).‒ Delay your travel home until after you have recovered or your doctor saysit is ok to travel.‒ If you get sick with fever, coughing, or shortness of breath after you returnto the United States, be sure to tell your doctor about your recent travel toChina.