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Swine influenza: the human
animal interface at Minnesota fairs
and live animal markets
Joni Scheftel DVM, MPH, dip ACVPM
State Public Health Veterinarian
Minnesota Department of Health
joni.scheftel@state.mn.us
651-201-5107
September 16, 2013
Dr. Joni Scheftel - The human animal interface at Minnesota fairs and live animal markets
History of Swine influenza
Infections in Humans in the US
Swine Influenza in People: Previously Rare
•  37 reported cases of swine influenza in
humans from 1958-2005, most with swine
contact, some with probable person-to-person
transmission CID, 2007
•  11 reported cases of triple-reassortant swine
influenza A (H1) from 2005-2009, most with
swine contact, no known person-to-person
transmission NEJM, 2009
Human Infections with SIV in MN
•  1996; H1N1; 37 Yr old F; swine contact; fatal
•  2008; rH1N1; 29 yr old F; Live animal
market; hospitalized briefly
•  2009; rH1N1; 29 yr old F; swine worker
•  2010 May; rH3N2; 1 yr old F; Live animal
market
•  2010 Dec; rH3N2; 31 yr old M; Live animal
market
•  2011; rH1N2; 5 mo-old F; no animal
exposure- sick family member
Swine-Origin Human Influenza Cases by Year and
Type, Minnesota, 1996-2012

10	
  

Number	
  of	
  Hospitaliza2ons	
  

9	
  
8	
  
7	
  

H1N2	
  
H3N2	
  
H1N1	
  

6	
  
5	
  
4	
  
3	
  
2	
  
1	
  
0	
  
Year	
  
U.S.	
  Cases	
  of	
  Variant	
  Influenza	
  A	
  through	
  
2012	
  
Confirmed Human Cases of H3N2v in the US,
Number cases
2012 (N = 306)
20
11
107
6
138
4

Date of onset, 2012

Slide from Dr. Sue Trock
H3N2v at State and
County Fairs in the US
and at the MN State
Fair during 2012

Slide thanks to Dr. Sue Trock
 

Human	
  H3N2v	
  Influenza	
  Cases	
  	
  
2012,	
  (n=	
  305)	
  
	
  States	
  with	
  confirmed	
  cases

	
  

	
  11	
  	
  

	
  
	
  Fairs	
  associated	
  with	
  human	
  cases 	
  39	
  
	
  
	
  Confirmed	
  cases 	
  

	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  

	
  309	
  

	
  Hospitalized	
  cases	
  

	
  

	
  	
  	
  

	
  16	
  

	
  Deaths

	
  

	
  

	
  	
  1	
  

	
  
	
  
	
  

	
  

	
  

Slide thanks to Dr. Sue Trock
Summary	
  of	
  Human	
  H3N2v	
  Cases,	
  2012	
  
	
  
•  Median	
  age	
  =	
  6	
  	
  y.o.	
  	
  (range	
  4	
  mo	
  –	
  74	
  y.o.)	
  
	
  
–  93%	
  less	
  than	
  18	
  y.o.	
  
•  Most	
  cases	
  occurred	
  in	
  young	
  swine	
  
exhibitors	
  at	
  county	
  fairs	
  with	
  several	
  days	
  
exposure	
  to	
  pigs	
  at	
  a	
  fair	
  
–  5%	
  of	
  cases	
  were	
  visitors	
  to	
  a	
  fair	
  
•  Incuba2on	
  period	
  ~	
  2	
  –	
  3	
  days	
  
•  Dura2on	
  of	
  illness	
  ~	
  3	
  –	
  4	
  days	
  

Slide thanks to Dr. Sue Trock
Distribu2on	
  of	
  H3N2v	
  Cases	
  and	
  Propor2on	
  of	
  Persons	
  with	
  
H3N2v	
  HI	
  An2body	
  Titer	
  ≥40	
  by	
  Age-­‐Group*	
  

Slide	
  from	
  Lynn	
  Finelli	
  
CDC	
  and	
  4-­‐H	
  Recommenda2ons,	
  2012	
  
People	
  at	
  high	
  risk	
  of	
  serious	
  
complica2ons	
  from	
  the	
  flu	
  
should	
  avoid	
  pigs	
  &	
  swine	
  barns	
  
at	
  the	
  fair	
  this	
  year	
  
	
  
High	
  Risk	
  groups	
  include:	
  
<	
  5	
  y.o.;	
  asthma,	
  diabetes,	
  lung	
  
or	
  heart	
  diseases,	
  or	
  other	
  long-­‐
term	
  health	
  condi2on;	
  pregnant	
  
women;	
  >	
  65	
  y.o.	
  	
  
	
  
	
  
	
  

Slide thanks to Dr. Sue Trock
Very Unpopular
Signage
Very, Very Unpopular Signage
Dr. Joni Scheftel - The human animal interface at Minnesota fairs and live animal markets
H3N2v and H1N2v Cases in Minnesota, 2012
human H3N2v

human probable H3N2v

human H1N2v

pig H3N2v

pig H1N2v

8

Number of Cases

7
6
5
4
3
2
1

0

H3

H1

H3

H1 H1

H3

H3

Case Onset Date

H1 H1 H1

H3
H1

H3

Minnesota	
  State	
  Fair	
  8/23-­‐9/3

H3
Why Not Minnesota County Fairs
in 2012 ?
•  The in-office test for influenza doesn’t work
for H3N2v
•  MDH Health Alert to HCP’s to submit
samples to MDH for special testing of cases
of influenza-like illness went out to clinics
on August 6, after most county fairs had
already occurred
•  Or maybe the virus didn’t start to circulate
among show pigs until later in the summer
Surprises and Things We Learned
in 2012
•  We were looking for H3N2v in swine
exhibitors at the fairs and found it at the
Live Animal Markets
•  Instead we found H1N2v in pigs and
people at the fair first
•  These were the first human cases of
H1N2v with the pandemic M gene in the
US
Good things came out of the
experience…
•  Great working relationships between
BAH, MDA, MDH, State Fair, 4H, U of MN,
communications people at all entities
•  Know more about the behavior of swine
influenza in people and pigs specifically
at fairs and potential for interventions
“Be Healthy at the Fair” Verbiage
•  People and animals can share germs
•  Wash your hands with soap and water
when you leave the barn
•  No food or drink in animal areas
•  Remove pacifiers and avoid hand to
mouth contact
•  Senior citizens, children under 5,
pregnant women and people with a
chronic health condition or a weak
immune system should take extra care
around animals
Dr. Joni Scheftel - The human animal interface at Minnesota fairs and live animal markets
Swine Exhibitions Group
•  Met January 15 and16, 2013
•  NASAHO and NASPHV Co-leads
–  AASV, CDC, IAFE, USDA, 4H, NPB, Ohio
State U, U of MN, Swine Registry,
NASAHO, and NASPHV
•  Audience: Fair/show organizers and
managers, 4H, FFA, Extension personnel,
exhibitors and their families, practicing
vets, animal health and public health
officials
Swine Exhibitions Group
•  Developed “Measures that may be
considered to minimize transmission of
influenza viruses between swine, between
people and swine and between swine and
people at swine exhibitions”
–  Prior to the exhibition
–  At the exhibition
–  After the exhibition
2013 Healthy Fairs Workshops
2013: Increased surveillance for
novel influenza infections
•  Sent Health Alert to remind HCP’s to
send nasal swabs for influenza testing
to MDH from people with ILI who report
swine contact
•  Set up system for sampling of sick 4H
kids at the state fair (same as 2012)
Postcard to 4H Families in the
Swine Project
	
  
	
  
	
  
	
  
July	
  12,	
  2013	
  
	
  
Dear	
  Swine	
  Exhibitor	
  and	
  Parents:	
  
	
  
Just	
   a	
  heads	
  up	
  that	
   there	
  have	
  been	
  cases	
   of	
  influenza	
  in	
  people	
   showing	
   swine	
  or	
  visiting	
   the	
   swine	
  barn	
  at	
   fairs	
  
in	
  Indiana.	
  So	
  far,	
  no	
  cases	
  have	
  been	
  identified	
  in	
  Minnesota,	
  but	
  we	
  want	
  to	
  be	
  prepared.	
  As	
  a	
  reminder,	
  if	
  you	
  
develop	
  flu-­‐like	
  symptoms	
  (cough,	
  sore	
  throat,	
  body	
  aches,	
  runny	
  nose,	
  or	
  fever)	
  within	
  a	
  week	
  of	
  the	
  fair	
  please	
  
talk	
  to	
  your	
  doctor	
  and	
  ask	
  to	
  have	
  a	
  nasal	
  swab	
  sent	
  to	
  the	
  Minnesota	
  Department	
  of	
  Health	
  for	
  testing.	
  	
  
	
  
If	
  you	
  have	
  questions	
  about	
  flu	
  in	
  pigs,	
  please	
  contact	
  the	
  Minnesota	
  Board	
  of	
  Animal	
  Health	
  at	
  651-­‐201-­‐6844;	
  if	
  
you	
  have	
  questions	
  about	
   the	
  flu	
  in	
  people,	
  please	
   contact	
  the	
  Minnesota	
   Department	
   of	
   Health	
  at	
   651-­‐201-­‐5414.	
  
For	
  information	
  on	
  measures	
  you	
  can	
  take	
  to	
  keep	
  your	
  pigs	
  healthy	
  before,	
  during,	
  and	
  after	
  the	
  fair,	
  please	
  go	
  to:	
  
http://usaha.org/.	
  	
  
	
  
Sincerely,	
  
	
  
	
  
Beth	
  Thompson,	
  JD,	
  DVM	
  
	
  
Joni	
  Scheftel,	
  DVM,	
  MPH	
  
	
  
Senior	
  Veterinarian	
   	
  
	
  
State	
  Public	
  Health	
  Veterinarian	
  
Minnesota	
  Board	
  of	
  Animal	
  Health	
   Minnesota	
  Department	
  of	
  Health	
  
U.S.	
  Cases	
  of	
  Variant	
  Influenza	
  A	
  
350
300

Cases

250
200
150
100
50
0
2005

2006

2007

2008

2009

Year

2010

2011

2012

2013
Swine-Origin Human Influenza Cases by Source of
Infection, Minnesota, 1996-Sept 14 2013

1
2

1
7

Live Animal Market
Fair
Swine Farm/Industry
Person-to-Person
Unknown

6
Dr. Joni Scheftel - The human animal interface at Minnesota fairs and live animal markets

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Dr. Joni Scheftel - The human animal interface at Minnesota fairs and live animal markets

  • 1. Swine influenza: the human animal interface at Minnesota fairs and live animal markets Joni Scheftel DVM, MPH, dip ACVPM State Public Health Veterinarian Minnesota Department of Health joni.scheftel@state.mn.us 651-201-5107 September 16, 2013
  • 3. History of Swine influenza Infections in Humans in the US
  • 4. Swine Influenza in People: Previously Rare •  37 reported cases of swine influenza in humans from 1958-2005, most with swine contact, some with probable person-to-person transmission CID, 2007 •  11 reported cases of triple-reassortant swine influenza A (H1) from 2005-2009, most with swine contact, no known person-to-person transmission NEJM, 2009
  • 5. Human Infections with SIV in MN •  1996; H1N1; 37 Yr old F; swine contact; fatal •  2008; rH1N1; 29 yr old F; Live animal market; hospitalized briefly •  2009; rH1N1; 29 yr old F; swine worker •  2010 May; rH3N2; 1 yr old F; Live animal market •  2010 Dec; rH3N2; 31 yr old M; Live animal market •  2011; rH1N2; 5 mo-old F; no animal exposure- sick family member
  • 6. Swine-Origin Human Influenza Cases by Year and Type, Minnesota, 1996-2012 10   Number  of  Hospitaliza2ons   9   8   7   H1N2   H3N2   H1N1   6   5   4   3   2   1   0   Year  
  • 7. U.S.  Cases  of  Variant  Influenza  A  through   2012  
  • 8. Confirmed Human Cases of H3N2v in the US, Number cases 2012 (N = 306) 20 11 107 6 138 4 Date of onset, 2012 Slide from Dr. Sue Trock
  • 9. H3N2v at State and County Fairs in the US and at the MN State Fair during 2012 Slide thanks to Dr. Sue Trock
  • 10.   Human  H3N2v  Influenza  Cases     2012,  (n=  305)    States  with  confirmed  cases    11        Fairs  associated  with  human  cases  39      Confirmed  cases                              309    Hospitalized  cases            16    Deaths        1             Slide thanks to Dr. Sue Trock
  • 11. Summary  of  Human  H3N2v  Cases,  2012     •  Median  age  =  6    y.o.    (range  4  mo  –  74  y.o.)     –  93%  less  than  18  y.o.   •  Most  cases  occurred  in  young  swine   exhibitors  at  county  fairs  with  several  days   exposure  to  pigs  at  a  fair   –  5%  of  cases  were  visitors  to  a  fair   •  Incuba2on  period  ~  2  –  3  days   •  Dura2on  of  illness  ~  3  –  4  days   Slide thanks to Dr. Sue Trock
  • 12. Distribu2on  of  H3N2v  Cases  and  Propor2on  of  Persons  with   H3N2v  HI  An2body  Titer  ≥40  by  Age-­‐Group*   Slide  from  Lynn  Finelli  
  • 13. CDC  and  4-­‐H  Recommenda2ons,  2012   People  at  high  risk  of  serious   complica2ons  from  the  flu   should  avoid  pigs  &  swine  barns   at  the  fair  this  year     High  Risk  groups  include:   <  5  y.o.;  asthma,  diabetes,  lung   or  heart  diseases,  or  other  long-­‐ term  health  condi2on;  pregnant   women;  >  65  y.o.           Slide thanks to Dr. Sue Trock
  • 17. H3N2v and H1N2v Cases in Minnesota, 2012 human H3N2v human probable H3N2v human H1N2v pig H3N2v pig H1N2v 8 Number of Cases 7 6 5 4 3 2 1 0 H3 H1 H3 H1 H1 H3 H3 Case Onset Date H1 H1 H1 H3 H1 H3 Minnesota  State  Fair  8/23-­‐9/3 H3
  • 18. Why Not Minnesota County Fairs in 2012 ? •  The in-office test for influenza doesn’t work for H3N2v •  MDH Health Alert to HCP’s to submit samples to MDH for special testing of cases of influenza-like illness went out to clinics on August 6, after most county fairs had already occurred •  Or maybe the virus didn’t start to circulate among show pigs until later in the summer
  • 19. Surprises and Things We Learned in 2012 •  We were looking for H3N2v in swine exhibitors at the fairs and found it at the Live Animal Markets •  Instead we found H1N2v in pigs and people at the fair first •  These were the first human cases of H1N2v with the pandemic M gene in the US
  • 20. Good things came out of the experience… •  Great working relationships between BAH, MDA, MDH, State Fair, 4H, U of MN, communications people at all entities •  Know more about the behavior of swine influenza in people and pigs specifically at fairs and potential for interventions
  • 21. “Be Healthy at the Fair” Verbiage •  People and animals can share germs •  Wash your hands with soap and water when you leave the barn •  No food or drink in animal areas •  Remove pacifiers and avoid hand to mouth contact •  Senior citizens, children under 5, pregnant women and people with a chronic health condition or a weak immune system should take extra care around animals
  • 23. Swine Exhibitions Group •  Met January 15 and16, 2013 •  NASAHO and NASPHV Co-leads –  AASV, CDC, IAFE, USDA, 4H, NPB, Ohio State U, U of MN, Swine Registry, NASAHO, and NASPHV •  Audience: Fair/show organizers and managers, 4H, FFA, Extension personnel, exhibitors and their families, practicing vets, animal health and public health officials
  • 24. Swine Exhibitions Group •  Developed “Measures that may be considered to minimize transmission of influenza viruses between swine, between people and swine and between swine and people at swine exhibitions” –  Prior to the exhibition –  At the exhibition –  After the exhibition
  • 25. 2013 Healthy Fairs Workshops
  • 26. 2013: Increased surveillance for novel influenza infections •  Sent Health Alert to remind HCP’s to send nasal swabs for influenza testing to MDH from people with ILI who report swine contact •  Set up system for sampling of sick 4H kids at the state fair (same as 2012)
  • 27. Postcard to 4H Families in the Swine Project         July  12,  2013     Dear  Swine  Exhibitor  and  Parents:     Just   a  heads  up  that   there  have  been  cases   of  influenza  in  people   showing   swine  or  visiting   the   swine  barn  at   fairs   in  Indiana.  So  far,  no  cases  have  been  identified  in  Minnesota,  but  we  want  to  be  prepared.  As  a  reminder,  if  you   develop  flu-­‐like  symptoms  (cough,  sore  throat,  body  aches,  runny  nose,  or  fever)  within  a  week  of  the  fair  please   talk  to  your  doctor  and  ask  to  have  a  nasal  swab  sent  to  the  Minnesota  Department  of  Health  for  testing.       If  you  have  questions  about  flu  in  pigs,  please  contact  the  Minnesota  Board  of  Animal  Health  at  651-­‐201-­‐6844;  if   you  have  questions  about   the  flu  in  people,  please   contact  the  Minnesota   Department   of   Health  at   651-­‐201-­‐5414.   For  information  on  measures  you  can  take  to  keep  your  pigs  healthy  before,  during,  and  after  the  fair,  please  go  to:   http://usaha.org/.       Sincerely,       Beth  Thompson,  JD,  DVM     Joni  Scheftel,  DVM,  MPH     Senior  Veterinarian       State  Public  Health  Veterinarian   Minnesota  Board  of  Animal  Health   Minnesota  Department  of  Health  
  • 28. U.S.  Cases  of  Variant  Influenza  A   350 300 Cases 250 200 150 100 50 0 2005 2006 2007 2008 2009 Year 2010 2011 2012 2013
  • 29. Swine-Origin Human Influenza Cases by Source of Infection, Minnesota, 1996-Sept 14 2013 1 2 1 7 Live Animal Market Fair Swine Farm/Industry Person-to-Person Unknown 6