CDC warns of swine flu outbreak at fairs

Previously reported on at this blog, here

US health officials on Friday warned the public to be careful around pigs after an outbreak of flu among visitors to county fairs.

The virus does not appear to have evolved to the point where it spreads easily among humans, but it does contain a gene from the pandemic H1N1 flu that sickened millions worldwide in 2009 and 2010.

"We are concerned that... may confer the potential for the virus to infect or spread among humans to a greater extent," said Joseph Bresee, an influenza epidemiologist at the Centers for Disease Control and Prevention.

The virus was first detected in July 2011 and there have since been a total of 29 known cases -- 16 of them in the past three weeks -- in the United States.

It is a relatively mild flu -- everyone recovered and only three people were hospitalized. As a result, many more cases have likely occurred without being reported to health officials.

The bulk of the reported cases were among children, who are more susceptible to swine flu.

With county fair season in full swing, health officials expect more people will get sick.

"We also expect some of the cases may be severe," Bresee cautioned.

Bresee urged people to go to the doctor if they feel flu symptoms after coming into contact with pigs so that public health officials can better track the outbreak.

"What we're really going to be looking for is evidence that the virus has made that change to spread efficiently among humans," he explained. "So far we haven't seen that."

Simple hygiene -- hand washing after contact with animals and not eating, drinking or putting things like cigarettes in your mouth while in animal areas -- can prevent the flu's transmission.

Pregnant women, children younger than five, the elderly and those with chronic illnesses should avoid exposure to pigs and swine barns.

This is an official CDC HEALTH ADVISORY: Increase in Influenza A H3N2v Virus Infections in Three U.S. States

August 3, 2012, 11:00 EST

Summary and Background

Multiple infections with variant* influenza A (H3N2v) viruses have been identified in 3 states in recent weeks. From July 12 through August 3, 2012, 16 cases of H3N2v were reported and confirmed by CDC. This virus was first detected in humans in July 2011. It has also been isolated in U.S. swine in many U.S. states. Since July 12, 2011, there have been 29 cases of H3N2v virus infection, including the 16 cases occurring in the last three weeks. All 29 cases were infected with H3N2v viruses that contain the matrix (M) gene from the influenza A (H1N1)pdm09 virus. This M gene may confer increased transmissibility to and among humans, compared to other variant influenza viruses. All cases have been laboratory-confirmed at CDC. Each of the 16 cases identified since July 12, 2012, reported contact with swine prior to illness onset; in 15 cases, contact occurred while attending or exhibiting swine at an agricultural fair. While the viruses identified in these cases are genetically nearly identical, separate swine exposure events in each state were associated with human infections. There is no indication that the cases in different states are epidemiologically related.

Clinical characteristics of the 16 H3N2v recent cases have been generally consistent with signs and symptoms of seasonal influenza, and have included fever, cough, pharyngitis, myalgia, and headache. No hospitalizations or deaths have occurred among the 16 confirmed cases since July 2012. Public health and agriculture officials are investigating the extent of disease among humans and swine, and additional cases are likely to be identified as the investigation continues.

Novel influenza A virus infection has been a nationally notifiable condition in the United States since 2007. Since that time, human infection with animal-origin influenza viruses has been rare, with ≤6 cases reported each year, until 2011 when 14 cases were identified. While most of the cases are thought to have been infected as a result of close contact with swine, limited human-to-human transmission of this virus was identified in some cases in 2011. Therefore, enhanced influenza surveillance is indicated, especially in regions and states with confirmed H3N2v cases.

Interim Recommendations for the Public

• Persons who are at high risk for influenza complications (e.g., underlying chronic medical conditions such as asthma, diabetes, heart disease, or neurological conditions, or who are pregnant or younger than 5 years, older than 65 years of age or have weakened immune systems) should consider avoiding exposure to pigs and swine barns this summer, especially if ill pigs have been identified.
• Persons engaging in activities that may involve swine contact, such as attending agricultural events or exhibiting swine, should wash their hands frequently with soap and running water before and after exposure to animals; avoid eating or drinking in animal areas; and avoid close contact with animals that look or act ill.
• Patients who experience influenza-like symptoms following direct or close contact with pigs and who seek medical care should inform their health care provider about the exposure.
• Patients with influenza-like illness who are at high risk for influenza complications (e.g., underlying chronic medical conditions such as asthma, diabetes, heart disease, or neurological conditions, or who are pregnant or younger than 5 years, older than 65 years of age or have weakened immune systems) should see their health care provider promptly to determine if treatment with antiviral medications is warranted.
• Influenza viruses have not been shown to be transmissible to people through eating properly handled and prepared pork or other products derived from pigs. For more information about the proper handling and preparation of pork, visit the USDA website fact sheet “Fresh Pork from Farm to Table.”

Interim Recommendations for Health Care Providers

• Clinicians who suspect influenza in persons with recent exposure to swine should obtain a nasopharyngeal swab or aspirate from the patient, place the swab or aspirate in viral transport medium, and contact their state or local health department to arrange transport and request a timely diagnosis at a state public health laboratory.
• Reverse-transcription polymerase chain reaction (RT-PCR) testing for influenza should be considered for patients with influenza-like illness prior to the start of the traditional influenza season in October.
• RT-PCR testing for influenza should be considered throughout the year for patients with influenza-like illness reporting recent swine exposure and for those who can be epidemiologically linked to confirmed cases of variant influenza.
• Commercially available rapid influenza diagnostic tests (RIDTs) may not detect H3N2v virus in respiratory specimens. Therefore, a negative rapid influenza diagnostic test result does not exclude infection with H3N2v or any influenza virus. In addition, a positive test result for influenza A cannot confirm H3N2v virus infection because these tests cannot distinguish between influenza A virus subtypes (they do not differentiate between human influenza A viruses and H3N2v virus). Therefore, respiratory specimens should be collected and sent for RT-PCR testing at a state public health laboratory.
• Clinicians should consider antiviral treatment with oral oseltamivir or inhaled zanamivir in patients with suspected or confirmed H3N2v virus infection. Antiviral treatment is most effective when started as soon as possible after influenza illness onset.

For more information:

• “Interim Guidance on Case Definitions to be Used for Investigations of Influenza A (H3N2) Variant Virus Cases” for state and local health departments is available at http://www.cdc.gov/flu/swineflu/case-definitions.htm.
• “Prevention Strategies for Seasonal and Influenza A(H3N2)v in Health Care Settings” is available at http://www.cdc.gov/flu/swineflu/prevention-strategies.htm.
• “Interim Guidance on Specimen Collection, Processing and Testing for Patients with Suspected Influenza A (H3N2) Variant Virus Infection” for public health professionals is available at http://www.cdc.gov/flu/swineflu/h3n2v-testing.htm, and
• “Interim Guidance for Influenza Surveillance: Additional Specimen Collection for Detection of Influenza A (H3N2) Variant Infections” for state and local health departments is available at http://www.cdc.gov/flu/swineflu/h3n2v-surveillance.htm.
• Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2011 is available at http://nasphv.org/documentsCompendiumAnimals.html

Categories of Health Alert messages:

• Health Alert - provides vital, time-sensitive information for a specific incident or situation; warrants immediate action or attention by health officials, laboratorians, clinicians, and members of the public; and conveys the highest level of importance. Example: HAN00001
• Health Advisory - provides important information for a specific incident or situation; contains recommendations or actionable items to be performed by public health officials, laboratorians, and/or clinicians; may not require immediate action. Example: HAN00316
• Health Update - provides updated information regarding an incident or situation; unlikely to require immediate action. Example: HAN00309
• HAN InfoService - provides general public health information; unlikely to require immediate action. Example: HAN00319

CDC Reports Cases 18-29 of H3N2v Virus Infection; Continues to Recommend Interim Precautions When Interacting with Pigs

August 3, 2012 – Today, CDC reported an additional 12 cases of human infection with influenza A (H3N2) variant virus (or “H3N2v virus”). These H3N2v viruses that are the same as previous H3N2v viruses identified in people and H3N2 viruses that have been found in U.S. swine. These cases occurred in three U.S. states; all occurred in people who had direct or indirect contact with swine and all but one case was associated with attendance at agricultural fairs where swine were present. Late summer is typically the fair season across the United States, and fairs are a setting that can provide many opportunities for exposures to occur between pigs and people. CDC continues to monitor the situation closely and recommends preventive actions to make people’s fair experience a safe and healthy one. >Learn more

CIDRAP: FLU NEWS SCAN: Grading federal pandemic plans, H7N3 in Mexico

Aug 2, 2012

GAO: Fed agencies' pandemic plans progressing but still have gaps
Federal agencies have made steady but uneven progress in their influenza pandemic planning efforts over the last 3 years, according to a new report from the US Government Accountability Office (GAO). As a follow-up to its 2009 progress report and as requested by Congress, the GAO found that 23 of 24 agencies have completed action-based pandemic plans, compared with 20 in 2009, says the report, which was released Aug 1 but is dated Jul 25. The GAO also said that all 24 federal agencies developed policies such as telecommuting to reduce employees' risk of contracting influenza and outlined plans for distributing hygiene supplies. Among shortcomings noted, however, were that only nine agencies have classified all or most jobs for on-site mission-essential functions by exposure risk level. The GAO also wrote, "There is limited oversight of agencies' progress to protect their employees during a pandemic." It recommended that the Department of Homeland Security (DHS) provide additional oversight of pandemic preparedness efforts and help focus attention on areas of uneven progress. The GAO said the DHS agreed with its recommendations.
Aug 1 GAO report
GAO report highlights

New H7N3 outbreaks in Mexico affect almost 18,000 poultry
Three new H7N3 avian flu outbreaks on Mexican poultry farms have infected almost 18,000 birds and killed 3,000, according to a report filed today with the World Organization for Animal Health (OIE). The outbreaks, all in Jalisco state, which has been battling the avian flu strain since mid June, totaled 17,854 cases, including 3,000 fatal ones. All three outbreaks began Jul 26 on farms near the city of Teocaltiche and may still be ongoing. In the OIE report, Mexico's National Food Quality, Food Safety and Health Service said it has tested 17,111 poultry samples and isolated 41 H7N3 viruses as part of its outbreak follow-up surveillance. Since the outbreak began, almost 5 million birds have died from the disease or been culled to prevent further transmission.
Aug 2 OIE report

Mumbai: 19-yr-old Chembur man first to die of swine flu in city since 2010

August 03, 2012

Excerpt:

Vinay Talewar, 19, who died at Kasturba Hospital, Chinkpokli, is the first Mumbai resident to succumb to the virus in the last two years. In April, a 23-year-old pregnant woman from Dhule had died of swine flu-related ailments at JJ Hospital.

Despite four deaths in MMR, civic authorities maintained there was no need to panic and recommended that high-risk patients such as pregnant women, the elderly, children and those with low immunity should exercise caution.

Civic authorities said Talewar suffered from epilepsy (a brain disease in which a person has repeated seizures) and was severely malnourished, weighing only 35 kg.

“He came to the hospital with acute breathlessness as a result of pneumonia. He was not even put on any antibiotic treatment for pneumonia,” said a doctor who treated Talewar. Doctors said that he died of pneumonia and had developed acute respiratory distress syndrome.

Talewar’s maternal uncle, Kiran Pawar, said that Talewar had been suffering from fever for the past 10 days and none of the doctors who treated him suspected swine flu. The civic body will screen people who came in contact with Talewar for the H1N1 virus.

The swine flu death toll in Navi Mumbai reached two on Wednesday, with the death of Suman Kamble, 44, who worked as an auxiliary nurse midwife at a health care centre run by the Navi Mumbai civic body in Vashi. Kamble had taken ill on July 18. She was admitted to a private hospital, Terna Sahyadri in Nerul, on July 27.

Mumbai: BMC gears up to tackle swine flu

Mumbai, August 03, 2012
The city’s first swine flu death has been a wake up call for the civic body which has now decided to screen patients for swine flu in the weekly (Sunday) health camps conducted in slums and slum-like regions. “Along with monsoon ailments, we will screen patients for H1N1 starting Sunday.

The civic body has decided to sensitise general practitioners as well as doctors in public hospitals about the H1N1 virus. “We will now have to educate doctors on the treatment protocol for H1N1 as we cannot afford H1N1 being mistaken for flu,” said a civic official.

According to Dr Om Shrivastav, infectious disease specialist, Tamiflu medicines are best if given within 48 hours of contracting the infection.
“People should be diagnosed early for effective treatment. Though H1N1 symptoms are similar to influenza, drugs used to treat it don’t work for H1N1,” Shrivastav said.

The BMC has initiated a drive on the lines of malaria control to screen swine flu patients.

“The BMC had good results with the malaria control programme with a nearly 70% drop in cases over two years. So, we have initiated a similar four-point programme for swine flu,” said Manisha Mhaiskar, additional commissioner, BMC.

Doctors said vaccination was important for high-risk patients such as pregnant women, senior citizens, small children and patients with low immunity. However, BMC officials said BMC did not recommend nor provide vaccines.

Maharashtra health officials worried over rising cases of swine flu

August 2, 2012

The death of Vinay Talewar, a 19-year-old youth from Chembur in Mumbai, is giving health experts a severe chill. Vinay died at the civic run Kasturba hospital on Wednesday. While this is the first fatality of swine flu in Mumbai city in close to two years, what is worrying state health officials is this year's rapid rise of people contracting swine flu.

Last year the state saw 316 positive cases of swine flu. This year till July, Mumbai alone has seen 213 positive cases of H1N1 virus.

The virus afflicting people in the monsoon is also one of the reasons why people don't take it seriously when they get ill. When Vinay fell sick on July 28, he and his family didn't realise that he had contracted swine flu. In fact not just him but even the local doctor he went to mistook his fever and cough that he was suffering from as just another common cold and began treating it the same way. Within a couple of days his family and doctors realised that he was suffering from some thing else as he stopped responding to the medicines and his condition began worsening. Doctors said that when he was finally admitted to Kasturba hospital it was too late.

According to Brihanmumbai Municipal Corporation (BMC) statistics 35 people tested positive in June and in July another 89 people tested positive. We are seeing more cases this month because a higher number of people are getting themselves tested for H1N1. However, people should avoid unnecessary testing as H1N1 is like any other seasonal influenza,” said Dr Mangala Gomare, epidemiologist, BMC.

Read more at: http://indiatoday.intoday.in/story/maharashtra-health-officials-worried-over-rising-cases-of-swine-flu/1/211532.html

Mumbai: H1N1 claims 2 lives in 24 hours

Excerpts:

MUMBAI: The H1N1 virus struck twice in the Mumbai Metropolitan Region, claiming the lives of a nurse from Navi Mumbai and a 19-year-old Chembur boy within a few hours on Wednesday. This is the first time since a pandemic broke out in 2009 that a healthcare worker fell to it.

Suman Kamble (44), an auxiliary nurse and midwife, was posted at a dispensary of the Navi Mumbai Municipal Corporation (NMMC) in Nerul. Chief health officer of NMMC Dr Ramesh Nikam said, "It is very unfortunate that this is the second death due to H1N1 in Navi Mumbai this year, and the fact that she was one of our staffers makes it worse." He added that Kamble was diagnosed as H1N1 positive on July 28 and since then, she had been on antiviral treatment. She died on Wednesday afternoon.

Vinay Talewar (19) was suffering from pneumonia and he also tested positive for H1N1; doctors at Kasturba Hospital in Chinchpokli suspect that his condition remained undiagnosed and untreated for at least 10 days. Malnourished, he weighed 35 kg, grossly underweight for his age. BMC officials also confirmed that he had a history of epilepsy.

Families of both the victims have already been screened. Nikam said Kamble was survived by her bank employee husband and a son. "Both have been given the antiviral as a preventive measure. A carpenter who had recently worked at their house has also been given the medicine," he said.

Ebola in Uganda

29 July 2012 - The Ministry of Health (MoH) of Uganda has notified WHO of an outbreak of Ebola haemorrhagic fever in Kibaale district in the western part of the country.

A total of 20 cases, including 14 deaths have been reported since the beginning of July 2012. The index case was identified in a family from Nyanswiga village, Nyamarunda sub-county of Kibaale district, where nine of the deaths were recorded. The deceased include a clinical officer who attended to a patient, and her four month-old child. Nine of the 14 deaths have occurred in a single household.

Laboratory confirmation was done by the Uganda Virus Research Institute in Entebbe.

Currently, two patients are hospitalized and are in stable condition. The first is a 38 year-old female who attended to her sister, the clinical officer who died. She was admitted to the hospital on 26 July 2012. The second is a 30 year-old female who participated in conducting the burial of the index case. She was admitted to the hospital on 23 July 2012. Both cases were admitted to hospital with fever, vomiting, diarrhoea and abdominal pain. Neither of the cases has so far shown bleeding, a symptom that often appears in viral haemorrhagic fever patients.

The MoH is working with stakeholders and partners to control the outbreak. Response plans at the national and district levels are being finalised. A national task force coordinated by the MoH has been re-activated at the MOH headquarters and holds daily meetings. In Kibaale a district task force has been formed to better coordinate field response. The neighbouring districts have been put on high alert about the outbreak and to step up surveillance.

A team of experts from MoH, WHO and Centers for Disease Control and Prevention (CDC) is in Kibaale to support the response operations. All possible contacts that were exposed to the suspected and confirmed cases since 6 July 2012 are being identified for active follow up. The necessary supplies and logistics required for supportive management of patients are being mobilized.

Kibaale hospital has established a temporary isolation ward for suspected, probable and confirmed cases. Médecins Sans Frontières (MSF), Holland, has mobilized necessary requirements for setting up isolation centre at the hospital. The MoH and Mulago Hospital have mobilized some staff to manage the isolation centre but more are urgently needed.

The MoH has advised the public to take measures to avert the spread of the disease and to report any suspected patient to the nearest health unit.

WHO does not recommend that any travel or trade restrictions are applied to Uganda.

Recombinomics: H3N2v Butler County Cluster Grows To 41

August 1, 2012
The Butler County Health Department received 41 calls reporting that 39 children and two adults had become sick after attending the week-long fair, which ended Saturday, said director Pat Burg.

Most of the people who became sick with the suspected H3N2v (variant) influenza virus had direct contact with hogs at the fair, she said.

Vast majority of the 41 in contact with pigs. Might be children exhibiting or friends of children exhibiting

There were 350 hog exhibitors at the fair, Burg said.

H3N2v can be transmitted from swine to humans and vice versa, officials said, but it is rarely transmitted between humans.

The above comments confirm that the number of symptomatic people linked to the Butler County Fair in Hamilton, Ohio was markedly higher than the 10 confirmed cases, which are record numbers for confirmed or suspect H3N2v cases at a single event. These numbers increase the likelihood that the H3N2v in Ohio matches the LaPorte County Fair outbreak in Indiana were there were 4 confirmed cases and at least 15 symptomatic cases identified via telephone survey.

The comment that the H3N2v is rarely transmitted between humans is false. The sequences from the LaPorte County Fair were closely related to the sequences from the West Virginia daycare center in late 2011. Two cases were confirmed, but 23 contacts were symptomatic and there was no swine exposure. The H3N2v was transmitting person to person for about a month, leading to flu-like symptoms in 23 of 70 contacts.

Like the Butler County and LaPorte County fairs, the majority of symptomatic cases are not tested, but are epidemiologically linked.
The identity between the West Virginia cluster and LaPorte cluster indicate this novel sub-clade, which is distinct from the first 10 confirmed cases in 2011, has adapted to humans and is leading to record numbers of confirmed and symptomatic cases.

The limited number of confirmed or reported cases is linked to surveillance failures, not transmission efficiency.

Flu-like outbreak linked to hogs at Butler County fair?

Aug. 1, 2012
HAMILTON — State and local health officials are investigating an outbreak of flu-like illnesses that may be linked to hogs at the Butler County Fair.

The Butler County Health Department received 41 calls reporting that 39 children and two adults had become sick after attending the week-long fair, which ended Saturday, said director Pat Burg.

Most of the people who became sick with the suspected H3N2v (variant) influenza virus had direct contact with hogs at the fair, she said.

There were 350 hog exhibitors at the fair, Burg said.
-snip-
If all of those suspected cases are confirmed as H3H2v, it would be the largest outbreak in the country in 2012, according to data from the CDC.

No one has been hospitalized, Burg said.

Continued: Click on title for full article.

Hawaii DOH Confirms H3N2v Virus

HONOLULU – Local and federal officials are investigating the cause of a confirmed variant flu case on Maui. The Hawaii State Department of Health (DOH) is working with federal and state partners, including the Centers for Disease Control and Prevention (CDC), the U.S. Department of Agriculture, and the Hawaii State Department of Agriculture (HDOA) to find the source of how a Maui resident adult contracted the virus, known as H3N2v virus.
The resident sought medical attention after experiencing symptoms consistent with the regular flu, including fever, cough, and body aches. Because the patient's primary care doctor is a participant in DOH’s influenza-like illness sentinel network (ILINet), a respiratory specimen was sent to the State Laboratories Division for testing. Lab results for H3N2v virus were confirmed by CDC late last week. The resident has since fully recovered without need for hospitalization.
"Fortunately, we have a robust surveillance network and our State Laboratory detected this variant virus and conferred with federal partners," stated Health Director Loretta Fuddy. "Thanks to the excellent cooperation of Hawaii's healthcare providers, participation in our sentinel network exceeds CDC recommendations. In addition to our state laboratory’s ability to identify unusual flu strains, sentinel physicians contribute to our ability to catch incidents such as this, which might otherwise fall below the radar."
The H3N2v virus identified in this case shares genetic similarities to variant flu viruses which have been identified in several other states in the past year. The H3N2v virus has rarely infected humans and has caused only limited human-to-human infection. The small number of previous infections has occurred mostly among children and those who work closely with pigs (e.g., livestock farmers). In this case, preliminary DOH findings suggest the latter exposure, although the investigation is ongoing in collaboration with HDOA.
“The virus seems to be behaving as previously observed in other cases, with illness similar to seasonal flu and with no sustained community transmission,” noted State Epidemiologist Dr. Sarah Park. “Still, anyone who develops flu-like illness within a week after close contact with domestic pigs should see their healthcare provider.”
Additionally, children, pregnant women, elderly, and those with compromised immune systems should be especially careful around pigs and practice good hand washing habits; those who work closely with pigs should take appropriate protective measures, including hand hygiene, personal protective equipment, and regular influenza vaccination.
“This particular virus is mainly transmitted through exposure to infected swine and is not transmitted through properly cooked pork,” said HDOA state veterinarian Dr. James Foppoli. “HDOA veterinarians will be taking samples to investigate the status of swine herds potentially associated with this case. The total number of human cases of swine derived influenza virus suggests that viral transmission from swine to humans is extremely uncommon. However, as in the past, we continue to emphasize that pig farmers and others having close contact with live swine practice good hygienic measures, such as frequent hand washing.”
Animal samples taken by HDOA will be tested by the DOH State Laboratory as part of their work as a member of the National Animal Health Laboratory Network.

CDC Reports Cases 14-17 of H3N2v Infection; Shares Advice for Safe Fair-Going

[Editing is mine]

July 27, 2012 -- The state of Indiana this week reported the first novel influenza virus outbreak associated with a fair this season. Following reports of ill swine and humans during a fair in Indiana from July 8-14, samples were taken from swine and humans. Twelve swine were randomly sampled by Indiana state animal health officials, tested at Indiana and federal animal diagnostic laboratories, and found to be infected with swine influenza A (H3N2) viruses. Four people tested positive for influenza A (H3N2) variant virus.* Genetic testing confirmed that the viruses found in humans and those found in swine are nearly identical, and both have the M gene from the pandemic H1N1 virus. These cases bring the total number of detected infections with the H3N2v virus containing the pandemic M gene in the United States since 2011 to 17.

Type A influenza viruses commonly infect swine, causing outbreaks among swine herds. Most of the type A influenza viruses that infect swine are genetically very different from human (seasonal) influenza viruses, including currently circulating seasonal H3N2 viruses. While swine flu viruses seldom infect humans, such infections can and do occur. In fact, influenza viruses can spread both from swine to humans and from humans to swine.

“Fairs are an important event for exhibitors and their swine, and a great experience for fairgoers,” says CDC Influenza Division Deputy Director Dr. Dan Jernigan, “but they are a venue for contact between people and swine. The detection of H3N2v at a few fairs last year, and its re-emergence at one fair so far this year makes this an issue to watch closely.”

The four cases reported by Indiana occurred in people who were exhibiting swine, or family members of people who were exhibiting swine, and were associated with swine contact. Previously, however, there have been H3N2v infections with no reported swine contact and instances of limited human-to-human transmission. “Of the 17 H3N2v infections detected to date, 11 have been associated with swine contact, and eight of these have been associated with fairs,” says Jernigan. In 6 cases, there has been no reported swine contact.

“There may be something different about the H3N2v virus in its ability to be more easily transmitted to people that warrants closer monitoring,” says Jernigan. There is some speculation that acquisition of the M gene from the pandemic H1N1 virus may make H3N2v viruses more transmissible.

According to the International Association of Fairs and Expositions (IAFE), “more than 3,200 fairs are held in North America each year. They provide industrial exhibits, demonstrations and competition aimed at the advancement of livestock, horticulture and agriculture with special emphasis placed on educational activities such as 4-H, FFA [Future Farmers of America] and similar youth development programs.” Swine are a common presence at such fairs.

“As fair season begins across the United States, CDC would like to let people know about some preventive actions they can take to make their fair experience a safe and healthy one,” says Jernigan.

The National Association of State Public Health Veterinarians has developed the Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2011 to provide some preventive actions that are applicable to people raising swine, showing swine at fairs, or attending fairs.

Ohio officials probe possible swine flu cases - Possible H3N2 Variant

August 1, 2012

CINCINNATI (AP) — Ohio health and agriculture officials said Wednesday they are investigating the cases of 10 sick humans whose illnesses have similarities to a swine flu virus. All had attended the same county fair.

State and Butler County health departments say preliminary laboratory tests indicate possible H3N2 variant flu virus, which can be contracted by humans from being around infected hogs. Officials say all 10 had contact with hogs at the Butler County Fair, which ended last weekend in Hamilton, in southwest Ohio.

The Centers for Disease Control and Prevention is also investigating, but hasn't confirmed swine flu.

Ohio Health Department spokeswoman Tessie Pollock said all 10 people are recovering from their illness. She wouldn't discuss any other details about them or their cases, citing health privacy concerns.

Swine flu symptoms include cough, sore throat, fever and body aches, and possibly nausea and diarrhea.

Indiana authorities last week said they were investigating similar cases involving four people who had swine contact at a northwest Indiana fair.

Pollock said Ohio authorities have been in contact with Indiana officials, and also with Ohio State Fair officials. The state fair continues through Sunday in Columbus. Health officials advise people to wash their hands after being near livestock and to keep food and drinks out of animal areas.

"This is no reason not to attend the fair," she said.

Health officials urge exhibitors at fairs to take precautions and for veterinarians to closely monitor swine for signs of illness.

There have been various strains of swine flu, including the H1N1 flu that caused a 2009 global pandemic.

Bad news: avian influenza virus can now infect mammals

Published 1 August 2012

A novel avian influenza virus has acquired the ability to infect aquatic mammals and was responsible for an outbreak of fatal pneumonia that recently struck harbor seals in New England; any outbreak of disease in domestic animals or wildlife, while an immediate threat to wildlife conservation, must also be considered potentially hazardous to humans

A novel avian influenza virus has acquired the ability to infect aquatic mammals and was responsible for an outbreak of fatal pneumonia that recently struck harbor seals in New England, according to scientists at the Center for Infection & Immunity (CII) at the Mailman School of Public Health, the National Oceanic and Atmospheric Association, New England Aquarium, USGS National Wildlife Health Center, SeaWorld, and EcoHealth Alliance.

This research is published in mBio (and see this New York Times article about the study).

A Columbia University’s Mailman School of Public Health release reports that wildlife officials first became concerned in September 2011, when seals with severe pneumonia and skin lesions suddenly appeared along the coastline from southern Maine to northern Massachusetts. Most were infants (less than six months old), and a total of 162 dead or moribund seals were recovered over the next three months.

Pathogen screening was conducted in a subset of afflicted seals, using sensitive diagnostic tools developed at CII. A new strain of avian H3N8 influenza virus was identified as a culprit.

“When initial tests revealed an avian influenza virus, we asked the obvious question: how did this virus jump from birds to seals?” says Simon Anthony, D.Phil, postdoctoral research scientist at CII and the lead author of the study.

Based on full genome sequencing and phylogenetic analysis, seal H3N8 descended from an avian strain that has been circulating in North American waterfowl since 2002, which implies recent transmission from wild birds to seals.

Accordingly, seal H3N8 has acquired the ability to bind sialic acid receptors that are commonly found in the mammalian respiratory tract. Mutations in the HA and PB2 genes — required for cell entry and replication, respectively – suggest enhanced virulence and transmission in mammals, but these putative attributes require further investigation. Given these findings along with the long history of the spread of avian influenza to humans — most notably H1N1 and H5N1 — seal H3N8 could pose a threat to public health.

“Our findings reinforce the importance of wildlife surveillance in predicting and preventing pandemics,” says W. Ian Lipkin, MD, director of the Center for Infection and Immunity and John Snow Professor of Epidemiology, at the Mailman School. “HIV/AIDS, SARS, West Nile, Nipah and influenza are all examples of emerging infectious diseases that originated in animals. Any outbreak of disease in domestic animals or wildlife, while an immediate threat to wildlife conservation, must also be considered potentially hazardous to humans.”

The research was funded by NIH - NIAID (AI057158); Defense Threat Reduction Agency (DTRA); the National Library of Medicine (R01 LM010140); and NIH - NCI (U54 CA121852-05).

Recombinomics: PB2 D701N In H3N8 Fatal Harbor Seal Infections

July 31, 2012

The seal H3N8 virus from the 2011 outbreak has naturally acquired this D701N substitution (Table 1), which was confirmed by clonal sequencing directly from infected tissue (50 clones/animal) to be the only phenotype present in all five animals.

The above comment is from the newly released mBio paper “Emergence of Fatal Avian Influenza in New England Harbor Seals” on a Columbia University analysis of sequences from 5 fatal infections in 2011 of New England habor seals by an avian H3N8. As noted above, all five PB2 sequences had D701N whih has been previously found in human H5N1 cases as well as lab experiments associating the change with increased transmission in mammals.

PB2 H5N1 changes have been of interest since E627K was identified in a sub-set of 1997 Hong Kong cased, which was followed by lab experiments demonstrating increased virulence in mice. The body temperature of birds is significantly higher than mammals, and position 627 can impact polymerase activity in a temperature sensitive manner. E627K is present in seasonal flu and enzymatic activity is optimal at 33 C, the temperature of a human nose in the winter. In contrast, PB2 with an E at position 627 has optimal activity at 41 C, the temperature of an avian intestine.

Recent H5N1 transmission experiments used H5N1 PB2 sequences with E627K, or H1N1pdm09 PB2 which has G590S and Q591R, which are known changes that can substitute for E627K to optimize polymerase activity in mammals.

In addition to G590S/Q591R substitution for E627K, another change, D701N also can substitute for E627K to increase transmission efficiencies in mammals. The PB2 sequence from the fatally infected seals had avian polymorphisms at positions 590, 591, and 627, but position 701 had D710N which is associated with mammalian transmission.

This change raises concerns that the avian H3N8 in the harbor seals has adapted to more efficient transmission and a higher viral load leading the the high mortality noted in 2011 for seals in the waters off the New England coast.

Further analysis of the PB2 sequences identified new acquisitions, including D710N found in H3N8 sequences from dogs and horses.

New influenza virus from seals highlights the risks of pandemic flu from animals

Previous posts at Pandemic Information News blog on the Seals can be found here:

Scientists: Bird Flu Virus Linked to New England Seal Deaths

New England seal deaths happened before, biologist says

New Hampshire: Seal Die-off Update: NOAA declares string of seal deaths an unusual mortality event

Flu virus identified in "unusual" New England seal deaths

31-Jul-2012

A new strain of influenza virus found in harbor seals could represent a threat to wildlife and human health, according to the authors of a study appearing July 31 in mBio®, the online open-access journal of the American Society for Microbiology. It is crucial to monitor viruses like this one, which originated in birds and adapted to infect mammals, the authors say, so that scientists can better predict the emergence of new strains of influenza and prevent pandemics in the future.

"There is a concern that we have a new mammalian-transmissible virus to which humans haven't been exposed yet. It's a combination we haven't seen in disease before," says Anne Moscona of Weill Cornell Medical College in New York City, the editor of the report.

The authors, who hail from several different institutions, including Columbia University and the National Oceanic and Atmospheric Administration Outbreaks, say transmissible and pathogenic flu viruses in mammals, like the one in this study, clearly pose a concern for human health. In 2009, for instance, the H1N1 "swine flu" virus that emerged in humans apparently originated from a reassortment of flu viruses found in birds, pigs, and humans. The H3N8 strain in New England harbor seals may come to represent the first sighting of a new group of influenza viruses with the potential to persist and move between species.

The mBio® study analyzed the DNA of a virus associated with a die-off of 162 New England harbor seals in 2011. Autopsies of five of the seals revealed they apparently died from infection with a type of influenza called H3N8, which is closely related to a flu strain that has been circulating in North American birds since 2002. Unlike the strain in birds, this virus has adaptations to living in mammals and has mutations that are known to make flu viruses more transmissible and cause more severe disease. The virus also has the ability to target a receptor called SAα-2,6, a protein found in the human respiratory tract.

Moscana says the study raises two concerns about flu. First, this strain is a novel virus that infects mammals and may well pass from animal to animal, a combination of traits that make it a potential threat to humans. Also, the possibility that a bird flu virus would infect seals hadn't been widely considered before, highlighting the fact that pandemic influenza can crop up in unexpected ways. She emphasizes the need for readiness.

"Flu could emerge from anywhere and our readiness has to be much better than we previously realized. We need to be very nimble in our ability to identify and understand the potential risks posed by new viruses emerging from unexpected sources," says Moscona. "It's important to realize that viruses can emerge through routes that we haven't considered. We need to be alert to those risks and ready to act on them."

Flu researchers bristle under federal policy

31 Jul 2012

Adolfo Garcia-Sastre

It has been four months since the US government issued a hastily released policy for monitoring what is called dual-use research of concern (DURC), research that could pose significant risks to the public if misapplied. At a meeting in New York on Monday, representatives of leading institutions that perform such research discussed their experiences fitting the new policy into their current procedures for managing research projects. Some were frustrated at the lack of definition in the policy and some expressed concern about what would be contained in an expansion of the policy that is soon to be released for public comment.

“We are trying to comply with as rational an approach as possible,” said Adolfo Garcia-Sastre, who runs one of the Centers of Excellence for Influenza Research and Surveillance (CEIRS) at Mount Sinai School of Medicine in New York, which hosted the meeting for other CEIRS researchers.

On 29 March, as US government advisers were considering as whether or not to publish two controversial papers describing a lab-created, mammalian-transmissible avian H5N1 strains of influenza, the government released a new DURC policy. It required federally funded institutions to take stock of any projects engaging in such research and develop plans for mitigating potential consequences. The policy was meant to shore up what some saw as a hole in the government’s approach to DURC, and government advisers said its existence was integral in persuading them to ultimately recommend publication of the two papers.

The researchers on the panel Monday morning included Yoshihiro Kawaoka of the University of Wisconsin–Madison and Ron Fouchier of Erasmus Medical Center in Rotterdam, the Netherlands, who finally published papers in May and June. Kawaoka described an approach to assessing the safety and appropriateness of laboratory protocols that is relatively unchanged since the adoption of the policy, except, he says, for the fact that it is put more specifically into the context of DURC. It means specific research protocols are assessed against a list of seven experimental approaches that should raise eyebrows.

Fouchier, with more than a bit of exasperation in his voice, described procedures for biosafety and security reviews that he says his group and institution have been in compliance with for years owing to existing laws. He urged fellow flu researchers to push back against what he feared would be further bureaucratic measures to come. Particularly worrying, he said, was that regulators are now taking issue with experiments — like the ones described in his recent paper — that result in a gain of function to existing pathogens. Fouchier said that these studies have to be done to fully understand how influenza works.

Michael Osterholm, a CEIRS leader at the University of Minnesota in Minneapolis and one of the government advisers to oppose full publication of Fouchier’s paper, said that he did not want to see extra layers of draconian regulation applied to his colleagues. But he says that the research can not proceed with a business-as-usual ethos. “If you want to see life sciences punished,” he warned, an accidental or intentional release of a deadly human pathogen will ensure it. The public’s reaction, he said, “will make anything we’re talking about here sound modest.” The goal, he said was not to limit research, but to communicate it responsibly. That may mean redacting certain elements, a stipulation that many academics won’t agree to.

Carole Heilman, director of the microbiology and infectious disease division at the National Institutes of Allergy and Infectious Disease in Bethesda, Maryland, cheekily advised the audience that “if you think there’s one point of view on this, I want to dissuade you from that.” Nevertheless, she said, “as a group we’re going to have to come to a position.”

This CEIRS meeting, the sixth annual but the first since the mutant H5N1 kerfuffle, may be a good place for researchers to start talking about consensus. Many expected that the meeting would be where flu researchers would finally agree to lift a moratorium on certain H5N1 research. It has been in place since January. And although it seemed that this meeting would be closed to the public, organizers decided at the last minute to open it up to reporters.

Robert Webster, a flu researcher at St Jude Children’s Research Hospital in Memphis, Tennessee, says: “This is a delicate time… . The public seems to think we have something to hide. We don’t have anything to hide and we’ve got to make sure that that’s made clear.”

Photo courtesy Mount Sinai School of Medicine

Novartis begins shipment of Fluvirin® seasonal influenza vaccine in US for 2012-2013 influenza season

[Editing is mine]

CAMBRIDGE, Mass., July 26, 2012 -- /PRNewswire/ -- Novartis announced today that the Company has commenced shipment of its seasonal influenza vaccine to customers in the US for the 2012-2013 influenza season. The early arrival of seasonal influenza vaccines will ensure healthcare professionals are equipped to provide the earliest possible protection against influenza. This year, Novartis plans to ship more than 30 million doses of the vaccine, which has been reformulated to include two new influenza strains to meet the updated World Health Organization and US Food and Drug Administration (FDA) recommendations. Fluvirin^® has been approved by FDA for persons 4 years of age and older².

During each season, influenza may cause thousands of influenza-associated deaths and hospitalizations^3,4. Federal health officials advise that the single best way to protect against influenza is to get vaccinated every year. Immunity to influenza viruses declines over time and may be too low to provide protection after one year⁵.

"We are continuing our dedication to meet customer demand by ensuring adequate supply of Fluvirin," said Brent MacGregor, President of US Vaccines and Head of Region North America. "The influenza vaccine will arrive in time to help meet a significant public health need and allow healthcare professionals to start administering vaccines in the lead up to the influenza season."

The Centers for Disease Control and Prevention (CDC) recommends routine seasonal influenza vaccination for all individuals 6 months of age and older. In addition, CDC advises that it is especially important for certain high-risk groups - seniors, children under the age of five, people with chronic illnesses such as asthma, diabetes or chronic lung disease and healthcare workers, as well as people who live with or care for high-risk individuals, to receive an influenza vaccine each influenza season¹.

About Seasonal Influenza

Seasonal influenza is a highly communicable, acute viral infection that predominantly attacks the respiratory tract and sometimes the lungs. It can cause mild to severe illness and can also lead to death³.

The number of people in the US who die every year from influenza and its complications could be comparable to the more than 41,500 people in the US who die each year from breast cancer, and to about half of the estimated 73,000 people who die annually of diabetes and its complications each year in the US^6,7.

Influenza vaccination is one of the most effective public health interventions ever implemented, sparing millions of people from complications, including death, from this infectious disease. Use of currently available seasonal influenza vaccines has been calculated to save more than 8 million lives annually worldwide, translating to one person saved every five seconds⁸.

About Fluvirin

Fluvirin vaccine is an inactivated influenza virus vaccine indicated for active immunization of persons 4 years of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine².

For the 2012-2013 season, Fluvirin contains antigens that target three influenza virus strains identified by World Health Organization (WHO) experts as likely to dominate circulation. These include:

• A/California/7/2009 (H1N1)-like virus

• A/Victoria/361/2011 (H3N2)-like virus

• B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses)

Important Safety Information

[continued - click on Title for full article]

From another article:
(Dated 2/28/12) background on vaccine choice:

SILVER SPRING, MD. – A Food and Drug Administration advisory panel on Feb. 28 recommended that the vaccine for the next influenza season should include two new strains and retain only one of the three strains in the current vaccine.

The FDA’s Vaccines and Related Biological Products Advisory Committee voted 18-0 that the 2012-2013 seasonal flu vaccine used in the United States should include the same influenza A (H1N1) component included in the 2011-2012 vaccine, an A/California/7/2009 (H1N1)-like virus. For the second influenza A strain in the vaccine, the panel’s vote was also unanimous, recommending that the influenza A (H3N2) component be replaced with an A/Victoria/361/2011 (H3N2)-like virus.

The panel voted 17-1 that that the influenza B strain be replaced with a B/Wisconsin/1/2010-like virus (B/Yamagata lineage). The current vaccine strain is a B/Brisbane/60/2008-like virus, a B/Victoria lineage strain. Panelists pointed out, however, that determining which B strain to select, a Victoria or Yamagata lineage B strain virus, is always challenging and said that this illustrated the utility of a quadrivalent influenza vaccine that contains B/Victoria lineage and B/Yamagata lineage viruses.

It appears that a quadrivalent influenza vaccine may soon be available, possibly as early as 2013. At the meeting, representatives of several vaccine manufacturers provided updates on the status of their quadrivalent influenza vaccines in development, including GlaxoSmithKline, which has filed for FDA approval of a quadrivalent influenza vaccine for people aged 3 and older.

The FDA panel’s recommendations are the same as the World Health Organization’s recommendations for the 2012-2013 Northern Hemisphere seasonal influenza vaccine, made at a meeting earlier in February.

The FDA panel meets at this time every year to recommend the strains to be included in the trivalent influenza vaccine in the United States in the upcoming season, considering information on the strains circulating worldwide and the WHO recommendation for the vaccine to be used in the Northern Hemisphere.

This influenza season has started late, in February, and flu activity has been low, although it is expected to increase, the Centers for Disease Control and Prevention announced last week.

The FDA usually follows the recommendations of its advisory panels. Panelists have been cleared of potential conflicts of interest related to the topic of the meeting. Occasionally, a panelist may be given a waiver, but not at this meeting.

Oxford Journals: Avian and pandemic human influenza policy in South-East Asia: the interface between economic and public health imperatives

Volume 27 Issue 5 August 2012

The aim of this study was to analyse the contemporary policies regarding avian and human pandemic influenza control in three South-East Asia countries: Thailand, Indonesia and Vietnam. An analysis of poultry vaccination policy was used to explore the broader policy of influenza A H5N1 control in the region. The policy of antiviral stockpiling with oseltamivir, a scarce regional resource, was used to explore human pandemic influenza preparedness policy. Several policy analysis theories were applied to analyse the debate on the use of vaccination for poultry and stockpiling of antiviral drugs in each country case study. We conducted a comparative analysis across emergent themes.

The study found that whilst Indonesia and Vietnam introduced poultry vaccination programmes, Thailand rejected this policy approach. By contrast, all three countries adopted similar strategic policies for antiviral stockpiling in preparation. In relation to highly pathogenic avian influenza, economic imperatives are of critical importance. Whilst Thailand's poultry industry is large and principally an export economy, Vietnam's and Indonesia's are for domestic consumption. The introduction of a poultry vaccination policy in Thailand would have threatened its potential to trade and had a major impact on its economy. Powerful domestic stakeholders in Vietnam and Indonesia, by contrast, were concerned less about international trade and more about maintaining a healthy domestic poultry population. Evidence on vaccination was drawn upon differently depending upon strategic economic positioning either to support or oppose the policy.

With influenza A H5N1 endemic in some countries of the region, these policy differences raise questions around regional coherence of policies and the pursuit of an agreed overarching goal, be that eradication or mitigation. Moreover, whilst economic imperatives have been critically important in guiding policy formulation in the agriculture sector, questions arise regarding whether agriculture sectoral policy is coherent with public health sectoral policy across the region.

1. Petcharat Pongcharoensuk¹,
2. Wiku Adisasmito²,
3. Le Minh Sat³,
4. Pornpit Silkavute⁴,
5. Lilis Muchlisoh²,
6. Pham Cong Hoat³ and
7. Richard Coker⁵,*

Vietnam: Implement urgent measures to prevent bird flu

Saturday, 28/07/2012
(HPDT) - On 27-7, Chairman of urgent city on the implementation of urgent measures to prevent bird flu in the province of Hai Phong city.

The power states: Currently, bird flu is occurring in six provinces, including provinces bordering or regular movement of poultry consumption in the province of Hai Phong such as: Hai Duong, Quang Ninh, Bac Ninh and Hung Yen. In Hai Phong, outbreaks occur from 18-7 in four communes of four districts (An Thai, An Lao district; ward Da Phuc, Ocean Business District; ward Trang Minh Kien An district, commune, Tran Duong, Vinh Bao District) and the total number of dead and sick poultry in the area destroyed by the date the city is 42,550 ducks 26-7.

The cause of a pandemic: As prevalence of avian influenza viruses in ducks 10% higher than normal, but ducks have inactive disease only when the resistance of ducks decreased due to weather , extreme climatic conditions or care, poor feeding, the virus is available in the body rise duck enhanced virulence and cause disease. Translation occurs only on the import of breeding ducks in late May 6-2012, the age of vaccination (14 days of age as prescribed), the time period 1-2012 vaccination ended on 30-6-2012 ; therefore not flock vaccination bird flu and no immunity on the other hand the same type of culture unknown origin, risk carriers.

Chairman directed the city: Consolidating PSC activities at all levels and disease prevention, allocation of specific responsibilities of each member Steering Committee; to direct the local authorities, departments, industry associations, local deployment preventive measures; concentrate all resources, material resources in service of the epidemic, implementing aggressive preventive measures in accordance with, quickly put out the service, not to translate widely spread; strict management of the outbreak, forbidden to transport, slaughter poultry in the epidemic promptly surrounded the outbreak vaccination, ensuring proper technique under the guidance of the Animal Health agency.

Form a team shock epidemic, the checkpoints are temporarily out to the service and inspect 24/24 tea seeds to control the movement of poultry, poultry products out in endemic areas, ban movement of poultry ill die out area. Strengthen propaganda on local radio system on the dangerous nature of the outbreaks and control measures to raise awareness for animal husbandry, poultry shall not sick, do not eat duck and other poultry poultry products, uncooked, in contact with birds must have personal protective equipment, wash your hands after contact poultry.