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Report on the investigation of acute febrile deaths in three children during the 2008 seasonal influenza outbreak in HKSAR: Summary and Recommendations.

Author(s)Expert Group on Investigation of Flu Deaths in Children
AbstractThe Panel investigated on events leading to the death of the three children in early 2008. The cause of death of HO Po-yi(F/3) is 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 include the stress of influenza A H3N2/Brisbane/10/2007 virus infection and the use of multiple drugs of similar nature. The relative contribution of these factors to her death is uncertain. OR Ho-yeung(M/2) died of acute myocarditis of unknown microbial aetiology though his elder sister had influenza B. LAW Ho-ming(M/7) had underlying asthma recently treated by steroid and died of acute necrotising encephalopathy due to influenza A H1N1/Brisbane/59/2007. Seasonal influenza occurs regularly due to antigenic drift. The increased incidence of influenza-like illness in our community surveillance in February/March 2008 is not unexpected because of the displacement of the H3N2/Wisconsin/67/2005-like and H1N1/Solomon Islands/3/2006-like viruses as well as the co-circulation of B/Yamagata/16/88-like and B/Victoria/2/87-like viruses. While such an increased incidence can be associated with increased cases of complications or death, the epidemiological data showed the situation is deemed not worse than previous years. At the time of report, childhood mortality from influenza during this influenza season in HKSAR was comparable with the influenza season in US (2003/04). The Panel made the following recommendations on how to reduce similar occurrence based on the epidemiological, clinical, toxicological and microbiological findings. A review should be conducted in respect of extending the recommended age range of childhood vaccination for influenza. Rapid-test guided antiviral treatment may be considered for close contacts with underlying medical illness who develop fever during school outbreaks. But empirical antiviral therapy should be discouraged because of emerging antiviral resistance and possible neuropsychiatric side effects in adolescents. School closure should be individualised but may be considered during outbreaks taking reference from the actual epidemiological situation as well as certain indicators such as when the sick leave rate is 10% or more, if hospitalisation rate is more than 1%, two or more ICU admissions,
or any death of healthy children in the school. Children with febrile illness during outbreak seasons should stay home till 48 hours post-defervescence for good recovery. Though earlier diagnosis, timely admission or changes in therapeutics for these three cases are unlikely to have changed the outcome, subtle clinical features such as repeated visits to doctors and narrow pulse pressure could be early clues for attending clinicians to consider admissions or more thorough investigations. The culture of polypharmacy especially with drugs of similar actions should be discouraged. Dosage of drugs should always be tailored according to accepted recommendations. When a patient has been prescribed medication by a doctor and is then taken to see another doctor, the prescribed medication should be shown to the latter. All drug bags should be labelled with generic names. For better protection of patients, the database of all patients should be linked between the private and public health service and made accessible to authorised health personnel so that any doctor can know exactly the diagnoses and drugs given by other doctors in previous consultations. A long term systematic surveillance for unexplained deaths and critical illnesses suspicious of an infectious aetiology should be maintained to pick up herald cases of emerging infectious diseases. At this stage in time, there is little epidemiological, clinical, pathological or virological evidence to suggest that the presently circulating influenza virus strains are more virulent than usual. Two of the children who died after contracting influenza also had some underlying medical problems. The findings and recommendations are aimed at lessons learnt and areas for further improvement as well as allaying undue concern of the virulence of the circulating influenza viruses. It is not the responsibility of the Panel to consider liability or blame of any particular party, and the findings and recommendations should not be read as the Panel’s views on such issues or as implying that the Panel has considered such issues.
Date of publishing04/18/2008
Date of last review by us05/31/2008
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Full ReviewReview byQuestions this resource addresses
Click here for full reviewECDCWhen these cases were first reported in March 2008, ECDC produced a rapid risk assessment highlighting that the cases and fatalities in Hong Kong were tragic, but unexceptional, and that they posed no enhanced risk to Europe though it is important that those travelling to Hong Kong and other equatorial areas appreciate that they may encounter influenza there at any time of the year but especially . . .


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