Mysterious pneumonia outbreak in China; symptoms to prevention tips, all you want to know

“China has reported an outbreak of mysterious influenza-like illness mostly among children recently. Children are presenting with high-grade fever without any other symptoms and further radiological investigations have revealed lung lesions. Some patients have been hospitalised for further management. There are numerous viruses such as Adenovirus, influenza virus, enterovirus, rhinovirus, RSV and Covid virus which can cause such symptoms. Important thing to be noted is that all viral infections do not necessarily cause the full spectrum of symptoms which we associate with common flu. Common symptoms of any viral infection are fever, with or without chills. There may be associated running nose, cough, SOB, vomiting and loose motions but it is not always necessary for additional symptoms to be there, says Dr Tushar Tayal, Consultant– Internal Medicine at CK Birla Hospital Gurugram.

“Recently, there has been a rise in pneumonia cases among children, particularly in certain areas of northern China, prompting concerns reminiscent of the events in November and December 2019. However, there is some relief as per a report from the World Health Organization (WHO). The Chinese government has clarified that these cases are attributed to known pathogens such as bacteria and viruses, including the influenza virus, respiratory syncytial virus, some COVID cases, and some mycoplasma cases. Given that the incidence of pneumonia typically increases during winter, it is hoped that this surge is seasonal. According to the WHO report, the Chinese government has identified the causes of these pneumonia cases, ruling out the presence of any new viruses or bacteria. Consequently, there is no immediate risk of the situation spreading globally or reaching India. While there is a sense of reassurance, it is important to remain cautious,” says Dr Sushila Kataria, Senior Director, Internal Medicine, Medanta, Gurugram.

“According to WHO, in their November 13 press meeting, China’s National Health Commission officials reported alarmingly large number of cases of respiratory diseases in the country. These infections are likely due to respiratory illnesses like influenza, mycoplasma pneumoniae (a common bacterial infection which typically affects younger children), respiratory syncytial virus (RSV), and SARS-CoV-2 (the virus that causes COVID-19). This surge in childhood infections is being linked to co-incidence between lifting of lockdown restrictions and the start of winter, when such respiratory infections are more prevalent. On 21 November, media and ProMED (part of the International Society for Infectious Diseases) reported clusters of undiagnosed pneumonia in children in northern China. It is unclear if these cases are associated with the overall increase in respiratory infections previously reported by Chinese authorities, or separate events. Since mid-October, northern China has reported an increase in influenza-like illness compared to the same period in the previous three years, says Dr. Gurmeet Singh Chabbra, Director-Pulmonary, Marengo Asia Hospitals Faridabad.

What are the symptoms of this mysterious pneumonia?

“Pneumonia is a lung infection affecting one or both lungs leading to the filling of air sacs (alveoli) with fluid or pus caused by bacteria, viruses like RSV- respiratory syncytial virus, Adenovirus, Influenza, Rhinovirus, COVID and bacteria like Mycoplasma pneumonia. It is diagnosed based on symptoms like cough, breathing difficulty, fever additive symptoms like loose stool and vomiting in children and chest X-ray. Recently, there has been an upsurge of influenza-like illness cases in children from Beijing and Liaoning Province of China, named ‘mysterious pneumonia’, because definite cause is still under investigation. It could be any of the pre-existing viruses like RSV, bacteria or atypical bacteria like Mycoplasma etc. This ‘mysterious pneumonia’ presents with high-grade fever and abnormal chest radiograph with no or minimal cough,” says Dr Dhirendra Pratap Singh, Consultant, PICU, Amrita Hospital, Faridabad.

“RSV (Respiratory Syncytial Virus) and mycoplasma pneumonia are thought to be the causes of this illness. They’re usually called atypical pneumonia. Symptoms of this type of pneumonia are not as strong and include fever, headache, extreme tiredness, a cough that doesn’t produce much phlegm, a sore throat, and a runny nose. This is why it’s sometimes called ‘walking pneumonia.’ In contrast, regular bacterial pneumonia can make a person very sick with high temperatures, low blood pressure, and trouble breathing. The reason for this difference is that the germs causing these types of pneumonia are different. To prevent the quick spread of any infection, it’s important to keep hands clean, avoid public transport and crowded places if you have symptoms, and get prompt medical attention for early diagnosis and the right antibiotics for a speedy recovery,” says Dr Rupkatha Sen, Chief Intensivist, SRV Hospitals – Chembur.

“The symptoms associated with this pneumonia include fever; however, notably, there is an absence of cough or breathlessness. This divergence from typical respiratory infections adds to the mystery surrounding the illness. The healthcare authorities are diligently investigating these cases, aiming to identify the responsible pathogen and establish effective management strategies. As the situation unfolds, continuous monitoring and research efforts are essential to comprehend the nature of this pneumonia and implement appropriate public health measures,” says Dr Rajesh Chawla, Senior consultant, pulmonology and critical care, Indraprastha Apollo Hospital

Why classic symptoms of pneumonia may be missing in China outbreak?

All symptoms of classical pneumonia may not manifest in every child depending upon age, co-existing comorbidity and cause of infection, says Singh.

“This pneumonia outbreak can be attributed to ‘immunity debt’- after lifting off of China’s lengthy lockdown in this peak season of respiratory illness which has drastically reduced immunity to respiratory bugs that is usually achieved by exposure. China reported a surge of Mycoplasma pneumonia or ‘walking pneumonia’, which, although usually presents itself as harmless, can also lead to challenges in respiration in some patients. It’s treated with macrolide antibiotics although macrolide resistance is increasing due to unnecessary misuse during any cold cough episode by the general population. It’s too early to comment on whether undiagnosed pneumonia is a new pandemic or an upsurge of existing infection until more information is available,” says Dr Singh.

“Possibly, withdrawal of restrictions after a prolonged period of lock down, exposed the Chinese population to number of respiratory infections. Having not been exposed to such respiratory infections since long, probably caused waning of their immunity to cope up with these infections, though some infections like mycoplasma pneumoniae and antigenically variable corona viruses themselves do not give prolonged immunity. Though lack of symptoms like cough is being reported, children are suffering from high fever and lung inflammation. Usually, such winter related infections have symptoms like sore throat, nasal discharge, sneezing, body ache, headache, chills with fever, cough which is usually dry, breathlessness, wheeze, confusion etc,” says Dr Chhabra.

“The absence of a cough or other classic respiratory symptoms in this pneumonia, despite the presence of fever in children, raises intriguing questions about the nature of the causative organism. It’s important to note that fever is a symptom commonly associated with various infections, and different bacteria or viruses may manifest with distinct sets of symptoms. The possibility that the responsible organism for this pneumonia may not induce cough is not entirely unusual. Infections can present in diverse ways, and it’s not uncommon for individuals to experience infections without displaying certain expected symptoms, such as coughing. This emphasizes the importance of considering a broad range of clinical presentations when investigating infectious diseases,” says Dr Chawla.

Preventive measures

Dr Chhabra advises that as a precautionary measure to prevent transmission of such diseases, which spread from person to person by infected respiratory droplets during close contact, it is advisable to follow measures like keeping distance from people who are ill, staying home when ill, getting tested and medical care as needed, wearing masks as appropriate, ensuring good ventilation, regular hand-washing and getting vaccinated.

“Like any communicable disease, personal protective measures will help limit the spread of this too- wearing masks, frequent hand washing, social distancing and staying at home when ill. It is advised to get the recommended vaccination, get tested for the disease and ensure medical care, and good ventilation. Another recommendation would be to not take antibiotics without paediatric consultation,” says Dr Singh.

“Preventive measures for the pneumonia spreading in China include adhering to crucial practices such as avoiding unnecessary travel, prioritizing personal hygiene, and maintaining a clean environment. Stressing the significance of frequent handwashing and practicing respiratory hygiene is paramount in minimizing the risk of infection. It’s noteworthy that these preventive measures, including vaccination against influenza, play a pivotal role in controlling the spread of respiratory illnesses. Although the situation may not be as prevalent in India, being proactive in adopting these measures remains essential for safeguarding public health,” says Dr Chawla.

Should India worry about this mystery pneumonia spread?

“In our own country, there may be an increase in influenza cases during the ongoing pandemic. Therefore, it is advisable to prioritize influenza vaccination and consistently practice cough etiquette to mitigate potential risks. Vigilance remains crucial despite the current understanding of the situation,” says Dr Kataria.

“We can assume that the etiological agent causing infection in Chinese children is a virus or some atypical bacteria, and proper research will be needed to find out the culprit organism so that it can be contained and effective strategies implemented. It is too early to say whether the current infection can become a pandemic or not and whether or not this infection will spread to India. WHO is already involved and is looking into the matter and has asked the Chinese govt to look into the matter. What is most important is to keep following personal protection in the form of 3 ply masks, frequent hand sanitization and social distancing,” says Dr Tayal.

“As of now, there isn’t enough information right now to say that pneumonia outbreak in the northern China can escalate and spread to India. Though we’ve witnessed this pneumonia spreading in subgroups, we need to remember that this is the winter of the Northern Hemisphere. We have always witnessed increase in the number of cases during winter across the world. When it comes to winter cases, we need to find out what is causing this, and Is there really an actual reason behind the increase in numbers or not. Just reporting for flu cases or pneumonia cases is very common during winter. We really don’t know if it’s a mysterious pneumonia or regular. We need to have more concrete information before we go ahead and classify it as one, and as of yet there’s no objective evidence,” says Dr Rahul Pandit, Chairperson of the Critical Care Department at Sir HN Reliance Foundation Hospital, Mumbai.

“This is the first winter of China after lifting up of lockdown restrictions. They are now experiencing a sudden rise in cases of pneumonia which is primarily affecting clusters of children, leading to significant absenteeism in schools. At this point, there is no identified novel virus as the cause, making it premature to speculate about potential additional risks of infection spread that could lead to a pandemic-like situation,” says Dr Sen.