1. H3N2 variant influenza A Maine, 2011 Sara Robinson, MPH Epidemiologist Maine Center for Disease Control and Prevention

2. H3N2 in Swine and Humans H3N2 began circulating in swine in the U.S. in 1998, introduced by humans Currently circulating swine flu H3N2 viruses are different from human H3N2s. Sporadic human infections with SI do occur usually in people exposed to swine at fairs or farm workers. Limited human-to-human spread.

3. Variant influenza A (H3N2v) This particular virus carries the M gene from the 2009 H1N1 virus. This virus first reported in a human from Indiana in July 2011. 12 total cases reported in 2011 – 2 in Indiana-3 in Iowa – 3 in Pennsylvania-2 in West Virginia – 2 in Maine 1 case reported to date in 2012, in Utah

4. Case A – lab information 10/14/2011 – Maine’s Health and Environmental Testing Laboratory (HETL) notified Maine CDC of an influenza A positive sample – Positive for H3, and the swine component of H1N1 – Sample collected as part of an enhanced surveillance initiative in Maine Sample forwarded to federal CDC for confirmation – confirmed as swine-origin triple reassortant influenza A(H3N2) on Monday 10/17/2011

5. Case A – Epi info 7 yo M with symptom onset of fever, cough, headache, sore throat and myalgia on 10/07/2011 Seen at providers office 10/10/2011 – Rapid influenza A positive – Sample taken for PCR testing (enhanced surveillance) Underlying conditions: asthma No 2011-2012 season influenza vaccine (vaccinated in 2010) Treated with Tamiflu Case A visited agricultural fair multiple days and spent time in the swine barn – No known direct contact with pigs

6. Agricultural Fair New swine barn at the fair with over 150 swine exhibited. 160,000 + attend this fair and many visit the swine exhibit (probably the only time that many people SEE a pig). Ten swine exhibitors at the fair from NH, MA and ME. Four pig scrambles held throughout the fair week, 10 baby pigs per scramble, 10-14 2 nd - 3 rd graders in each event.

7. Agricultural and Epi Response Investigation revealed there were some sick pigs at the fair and one of the scramble pigs died. All farms were visited and all pigs examined by a regulatory veterinarian. USDA guidelines only recommend testing swine with influenza-like illness. Samples submitted from two farms, both negative. Numerous people with ILI identified through farm contacts, all interviewed, several tested, all negative.

8. Epi Response Sent health alert state wide Notified area providers and hospitals Encouraged PCR testing (notified area commercial labs) Contacted case’s school to enhance surveillance Contacted schools that participated in pig scramble to enhance surveillance – Several ill individuals identified, all tested negative for influenza

9. Case B – lab information 10/28/2011 –HETL notified Maine CDC of an influenza A positive sample – Positive for H3 – High CT count Provider noted swine contact on submission form, sent for confirmation because of epi link Sample forwarded to federal CDC for confirmation – confirmed as swine-origin triple reassortant influenza A(H3N2) on Monday 10/31/2011

10. Case B – epi information 8 yo M with symptom onset of fever, myalgia, and runny nose on 10/22/2011 Seen at providers office 10/24/2011 – Sample taken for PCR testing No 2011-2012 season influenza vaccine (vaccinated in 2010) Case A visited agricultural fair multiple days and participated in a pig scramble, winning one of the pigs Case helped take care of pigs at family friend’s farm

11. Secondary Response Contacted farm where pig was located – This farm had been visited after the 1 st case was identified 2 secondary farms bought pigs from this farm – Both were visited, ill swine swabbed One pig was PCR positive, but unable to isolate virus – inconclusive results Contacted family – Sibling was ill with ILI, but influenza testing was negative, viral culture also negative

12. Timeline Fair 10/7 Swine samples collected Swine samples collected Health Alert (human and animal) Lab confirmation Case B Lab confirmation Case A Case B onset Case A onset 10/210/9 10/17 10/22 10/27 10/19 10/31 11/9 No additional human cases detected

13. Conclusions Both cases had documented swine exposure No human to human transmission identified Plenty of sick pigs, and sick humans but difficult to get positive influenza tests Increased awareness important Importance of PCR testing Importance of collaboration with the lab, and with the Department of Agriculture

14. Acknowledgements Maine CDC – Stephen Sears – Lauren Ball – Kate Colby – Heidi Mallis – Lori Webber – Brian Bernier USDA – Chip Ridky – Frederic Cantor – Nicole Giguere – Bill Smith Department of Agriculture – Don Hoenig – Beth McEvoy New Hampshire – Stephen Crawford – John Dreisig Massachusetts – Lorraine O’Connor Federal CDC