title: A case report of avian influenza H7N9 killing a young doctor in Shanghai, China.
abstract: BACKGROUND
  The novel avian influenza H7N9 virus has caused severe diseases in humans in eastern China since the spring of 2013. On January 18(th) 2014, a doctor working in the emergency department of a hospital in Shanghai died of H7N9 virus infection. To understand possible reasons to explain this world's first fatal H7N9 case of a health care worker (HCW), we summarize the clinical presentation, epidemiological investigations, laboratory results, and prevention and control policies and make important recommendations to hospital-related workers.
  
  
  METHODS
  The patient was a 31-year-old male Chinese surgeon who was obese and had a five-year history of hypertension and suspected diabetes. On January 11(th) 2014, he showed symptoms of an influenza-like illness. Four days later, his illness rapidly progressed with bilateral pulmonary infiltration, hypoxia and lymphopenia. On January 17th, the case had a high fever, productive cough, chest tightness and shortness of breath, so that he was administered with oseltamivir, glucocorticoid, immunoglobulin, and broad-spectrum antibiotic therapy. The case died in the early morning of next day after invasive ventilation. He had no contact with poultry nor had he visited live-poultry markets (LPMs), where positive rates of H7N9 were 14.6 % and 18.5 %. Before his illness, he cared for three febrile patients and had indirect contact with one severe pneumonia patient. Follow-up with 35 close contacts identified two HCWs who had worked also in emergency department but had not worn masks were anti-H7N9-positive. Viral sequence identity percentages between the patient and two LPM-H7N9 isolates were fewer than between the patient and another human case in shanghai in January of 2014.
  
  
  CONCLUSIONS
  Important reasons for the patient's death might include late treatment with oseltamivir, and the infected H7N9 virus carrying both mammalian-adapted signature (HA-Q226L) and aerosol transmissibility (PB2-D701N). The LPM he passed every day was an unlikely source of his infection, but a contaminated environment, or an unidentified mild/asymptomatic H7N9 carrier were more probable. We advocate rigorous standard operating procedures for infection control practices in hospital settings and evaluations thereafter.
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. panhao@scdc.sh.cn.
authors.forename: Hao
authors.initials: H
authors.lastname: Pan
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. zhangxi@scdc.sh.cn.
authors.forename: Xi
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. hujiayu@scdc.sh.cn.
authors.forename: Jiayu
authors.initials: J
authors.lastname: Hu
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. chenjian@scdc.sh.cn.
authors.forename: Jian
authors.initials: J
authors.lastname: Chen
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. panqichao@scdc.sh.cn.
authors.forename: Qichao
authors.initials: Q
authors.lastname: Pan
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. tengzheng@scdc.sh.cn.
authors.forename: Zheng
authors.initials: Z
authors.lastname: Teng
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. zhengyaxu@scdc.sh.cn.
authors.forename: Yaxu
authors.initials: Y
authors.lastname: Zheng
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. maoshenghua@scdc.s.cn.
authors.forename: Shenghua
authors.initials: S
authors.lastname: Mao
authors.affiliation: Department of Infectious Disease Control and Prevention, Pudong District Center for Disease Control and Prevention, No 3039, ZhangYang Road, Shanghai, 200136, China. zeroluna1011@139.com.
authors.forename: Hong
authors.initials: H
authors.lastname: Zhang
authors.affiliation: College of Public Health, National Taiwan University, Taipei, 100, Taiwan. chwanchuen@gmail.com.
authors.forename: Chwan-Chuen
authors.initials: CC
authors.lastname: King
authors.affiliation: Department of Infectious Disease Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, No 1380, West Zhongshan Road, Shanghai, 200336, China. wufan@scdc.sh.cn.
authors.forename: Fan
authors.initials: F
authors.lastname: Wu
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002681:China; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007136:Immunoglobulins / Q000627:therapeutic use; D064766:Influenza A Virus, H7N9 Subtype / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D007251:Influenza, Human / Q000175:diagnosis* / Q000188:drug therapy / Q000821:virology; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D053139:Oseltamivir / Q000627:therapeutic use; D010802:Phylogeny; D010820:Physicians; D011014:Pneumonia; D012367:RNA, Viral / Q000032:analysis; D011859:Radiography; D020133:Reverse Transcriptase Polymerase Chain Reaction
chemical_list: D000900:Anti-Bacterial Agents; D005938:Glucocorticoids; D007136:Immunoglobulins; D012367:RNA, Viral; D053139:Oseltamivir