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{{Expand-section|date=April 2009}}
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[[File:AntigenicShift_HiRes.png|thumb|250px|right|Swine can be infected by both avian and human influenza strains of influenza, and therefore are hosts where the [[antigenic shift]]s can occur that create new influenza strains.]]
[[File:AntigenicShift_HiRes.png|thumb|250px|right|Swine can be infected by both avian and human influenza strains of influenza, and therefore are hosts where the [[antigenic shift]]s can occur that create new influenza strains.]]
The transmission from swine to human is believed to occur mainly in swine farms where farmers are in close contact with live pigs. Although strains of swine influenza are usually not able to infect humans this may occasionally happen, so farmers and veterinarians are encouraged to use a face mask when dealing with infected animals. The use of vaccines on swine to prevent their infection is a major method of limiting swine to human transmission.
The transmission from swine to human is believed to occur mainly in swine farms where farmers are in close contact with live pigs. Although strains of swine influenza are usually not able to infect humans this may occasionally happen, so farmers and veterinarians are encouraged to use a face mask when dealing with infected animals. The use of vaccines on swine to prevent their infection is a major method of limiting swine to human transmission. Risk factors that may contribute to swine-to-human transmission include smoking and not wearing gloves when working with sick animals.<ref>{{cite journal |author=Ramirez A, Capuano AW, Wellman DA, Lesher KA, Setterquist SF, Gray GC |title=Preventing zoonotic influenza virus infection |journal=Emerging Infect. Dis. |volume=12 |issue=6 |pages=996–1000 |year=2006 |month=June |pmid=16707061 |pmc=1673213 |doi= |url=http://www.cdc.gov/ncidod/eid/vol12no06/05-1576.htm}}</ref>


=== Prevention of spread in humans ===
=== Prevention of spread in humans ===

Revision as of 18:59, 1 May 2009

This article is about swine-borne strains of influenza in general. For the 2009 outbreak in humans, see 2009 swine flu outbreak.
Influenza (flu)
H1N1 virus
Types
Vaccines
Treatment
Pandemics
Outbreaks
See also
Swine influenza is endemic in pigs

Swine influenza (also called swine flu, hog flu, and pig flu) refers to influenza caused by the influenza virus endemic in pigs (swine). Strains endemic in swine are called swine influenza virus (SIV).[1] SIV is common in pigs in the midwestern United States (and occasionally in other states), Mexico, Canada, South America, Europe (including the United Kingdom, Sweden, and Italy), Kenya, China, Japan, Taiwan, and other parts of eastern Asia.[1]

Direct transmission of a swine flu virus from pigs to humans is occasionally possible (this is called zoonotic swine flu). People who work with swine, especially people with intense exposures, are at risk of catching swine influenza if the swine carry a strain able to infect humans. However, only about fifty such cases of direct infection have been recorded in the medical literature throughout the 20th century. However, these strains infrequently circulate between humans as SIV rarely mutates into a form able to pass easily from human to human. In humans, the symptoms of swine flu are similar to those of influenza and of influenza-like illness in general, namely chills, fever, sore throat, muscle pains, severe headache, coughing, weakness and general discomfort.

The 2009 flu outbreak in humans that is widely known as "swine flu" is due to a new strain of influenza A virus subtype H1N1 that was produced by reassortment from one strain of human influenza virus, one strain of avian influenza virus, and two separate strains of swine influenza virus. The origins of this new strain are unknown, and the World Organization for Animal Health (OIE) reports that this strain has not been isolated in pigs.[2] It passes with apparent ease from human to human, an ability attributed to an as-yet unidentified mutation.[3] The strain in most cases causes only mild symptoms and the infected person makes a full recovery without requiring medical attention and without the use of antiviral medicines.[4]

Classification

Of the three genera of human flu, two are also able to infect pigs, with Influenzavirus A being common in pigs and Influenzavirus C being rare.[5] Influenzavirus B has not been reported in pigs. Within Influenzavirus A and Influenzavirus C, the strains found in pigs and humans are largely distinct, although due to reassortment there have been transfers of genes among strains crossing swine, avian, and human species boundaries.

Influenza C

Influenza C viruses infect both humans and pigs, but do not infect birds.[6] Transmission between pigs and humans have occurred in the past.[7] For example, influenza C caused a small outbreaks of a mild form of influenza amongst children in Japan,[8] and California.[9] Due to its limited host range and the lack of genetic diversity in influenza C, this form of influenza does not cause pandemics in humans.[10]

Influenza A

Swine influenza is known to be caused by influenza A subtypes H1N1,[11] H1N2,[11] H3N1,[12] H3N2,[11] and H2N3.[13]

In pigs, three influenza A virus subtypes (H1N1, H3N2, and H1N2) are the most common strains worldwide.[14] In the United States, the H1N1 subtype was exclusively prevalent among swine populations before 1998; however, since late August 1998, H3N2 subtypes have been isolated from pigs. As of 2004, H3N2 virus isolates in US swine and turkey stocks were triple reassortants, containing genes from human (HA, NA, and PB1), swine (NS, NP, and M), and avian (PB2 and PA) lineages.[15]

A/California/2009 (H1N1)

Main article: 2009 swine flu outbreak

A/California/2009 (H1N1), the new strain of swine influenza A (H1N1) involved in the 2009 flu outbreak in humans, is a reassortment of several strains of influenza A virus subtype H1N1 that are usually found separately, in humans, birds, and pigs. Preliminary data suggest that the hemagglutinin (HA) gene was similar to that of swine flu viruses present in United States pigs since 1999, but the neuraminidase (NA) and matrix protein (M) genes resembled viruses present in European pigs. Viruses with this genetic makeup had not previously been found to be circulating in humans or pigs. Although there is no formal national surveillance system to determine what viruses are circulating in pigs in the United States,[16] but United States pig producers do participate in surveillance programs. The origins of this new strain remain unknown.

History

The various types of influenza viruses in humans. Solid squares show the appearance of a new strain, causing recurring influenza pandemics. Broken lines indicate uncertain strain identifications.[17]

The H1N1 form of swine flu is one of the descendants of the Spanish flu that caused a pandemic in humans in 1918–1919.[18][19] As well as persisting in pigs, the descendants of the 1918 virus have also circulated in humans through the 20th century, contributing to the normal seasonal epidemics of influenza.[18] However, direct transmission from pigs to humans is rare, with only 12 cases in the U.S. since 2005.[20]

The influenza virus constantly changes form, thereby eluding the protective antibodies that people may have developed in response to previous exposures to influenza or to influenza vaccines. Every two or three years the virus undergoes minor changes. But at intervals of roughly a decade, after the bulk of the world's population has developed some level of resistance to these minor changes, it undergoes a major change that enables it to easily infect populations around the world, often infecting hundreds of millions of people whose antibody defenses are unable to resist it.[21] The influenza virus has also been known to change form over a much shorter period of time. For instance, during the Spanish flu pandemic, the initial wave of the disease was relatively mild, while the second wave of the disease a year later was highly lethal.[19]

For almost 60 years, from the first isolation in 1930 through 1998, SIV strains were almost exclusively H1N1. Then, between 1997 and 2002, novel viruses of three different subtypes and five different genotypes emerged as agents of influenza among pigs in North America. In 1997-1998, H3N2 strains emerged. These strains, which include genes derived by reassortment from human, swine and avian viruses, have become a major cause of swine influenza in North America. Reassortment between H1N1 and H3N2 produced H1N2. In 1999 in Canada, a strain of H4N6 crossed the species barrier from birds to pigs, but was contained on a single farm.[22]

Medical researchers worldwide, recognizing that swine influenza viruses might mutate into something as deadly as the Spanish flu, are carefully watching the 2009 H1N1 outbreak in humans and making contingency plans for a possible global pandemic. Several countries took precautionary measures to reduce the chances for a global pandemic of the disease.[23]

Transmission

Electron microscope image of the reassorted H1N1 virus. The viruses are 80–120 nanometres in diameter.[24]

Transmission between pigs

The main route of transmission is through direct contact between infected and uninfected animals.[14] These close contacts are particularly common during animal transport. The direct transfer of the virus probably occurs either by pigs touching noses, or through dried mucus. Airborne transmission through the aerosols produced by pigs coughing or sneezing are also an important means of infection.[14]

Transmission to humans

People who work with poultry and swine, especially people with intense exposures, are at increased risk of zoonotic infection with influenza virus endemic in these animals, and constitute a population of human hosts in which zoonosis and reassortment can co-occur.[25] Transmission of influenza from swine to humans who work with swine was documented in a small surveillance study performed in 2004 at the University of Iowa.[26] This study among others forms the basis of a recommendation that people whose jobs involve handling poultry and swine be the focus of increased public health surveillance.[25] The 2009 swine flu outbreak is an apparent reassortment of several strains of influenza A virus subtype H1N1, including a strain endemic in humans and two strains endemic in pigs, as well as an avian influenza.[27]

Interaction with avian H5N1 in pigs

Pigs are unusual as they can be infected with influenza strains that usually infect three different species: pigs, birds and humans.[28] This makes pigs a host where influenza viruses might exchange genes, producing new and dangerous strains.[28] Avian influenza virus H3N2 is endemic in pigs in China and has been detected in pigs in Vietnam, increasing fears of the emergence of new variant strains.[29] H3N2 evolved from H2N2 by antigenic shift.[30] In August 2004, researchers in China found H5N1 in pigs.[31]

Nature magazine reported that Chairul Nidom, a virologist at Airlangga University's tropical disease center in Surabaya, East Java, conducted a survey of swine infections with H5N1 in 2005. He tested the blood of 10 apparently healthy pigs housed near poultry farms in West Java where avian flu had broken out. Five of the pig samples contained the H5N1 virus. The Indonesian government has since found similar results in the same region. Additional tests of 150 pigs outside the area were negative.[32][33]

Signs and symptoms

In swine

File:Swine influenza symptoms on swine.svg
Main symptoms of swine flu in swines.

In pigs influenza infection produces fever, lethargy, sneezing, coughing, difficulty breathing and decreased appetite.[14] In some cases the infection can cause abortion. Although mortality is usually low, the virus can produce weight loss and poor growth, causing economic loss to farmers.[14] Infected pigs can loose up to 12 pounds of body weight over a 3 to 4 week period.[14]

In humans

Main symptoms of swine flu in humans[34]
See also: The Centers for Disease Control and Prevention (CDC): Symptoms of Swine Flu in YouTube

Direct transmission of a swine flu virus from pigs to humans is occasionally possible (this is called zoonotic swine flu). In all, 50 cases are known to have occurred throughout the 20th century, which resulted in six deaths.[35] Of these six people, one was pregnant, one had leukemia, one had Hodgkin disease and two were known to be previously healthy.[35] Despite these apparently low numbers of infections, the true rate of infection may be higher, since most cases only cause a very mild disease, they will probably never be reported or diagnosed.[35]

According to the Centers for Disease Control and Prevention (CDC), in humans the symptoms of the 2009 "swine flu" H1N1 virus are similar to those of influenza and of influenza-like illness in general. Symptoms include fever, cough, sore throat, body aches, headache, chills and fatigue. The 2009 outbreak has shown an increased percentage of patients reporting diarrhea and vomiting.[36] The 2009 H1N1 virus is not zoonotic swine flu, as it is not transmitted from pigs to humans, but from person to person.

Because these symptoms are not specific to swine flu, a differential diagnosis of probable swine flu requires not only symptoms but also a high likelihood of swine flu due to the person's recent history. For example, during the 2009 swine flu outbreak in the United States, CDC advised physicians to "consider swine influenza infection in the differential diagnosis of patients with acute febrile respiratory illness who have either been in contact with persons with confirmed swine flu, or who were in one of the five U.S. states that have reported swine flu cases or in Mexico during the 7 days preceding their illness onset."[37] A diagnosis of confirmed swine flu requires laboratory testing of a respiratory sample (a simple nose and throat swab).[37]

Prevention

Prevention of swine influenza has three components: prevention in swine, prevention of transmission to humans, and prevention of its spread among humans.

Prevention in swine

Methods of preventing the spread of influenza among swine include facility management, herd management, and vaccination. Because much of the illness and death associated with swine flu involves secondary infection by other pathogens, control strategies that rely on vaccination may be insufficient.

Control of swine influenza by vaccination has become more difficult in recent decades, as the evolution of the virus has resulted in inconsistent responses to traditional vaccines. Standard commercial swine flu vaccines are effective in controlling the infection when the virus strains match enough to have significant cross-protection, and custom (autogenous) vaccines made from the specific viruses isolated are created and used in the more difficult cases.[38][39] Present vaccination strategies for SIV control and prevention in swine farms, typically include the use of one of several bivalent SIV vaccines commercially available in the United States. Of the 97 recent H3N2 isolates examined, only 41 isolates had strong serologic cross-reactions with antiserum to three commercial SIV vaccines. Since the protective ability of influenza vaccines depends primarily on the closeness of the match between the vaccine virus and the epidemic virus, the presence of nonreactive H3N2 SIV variants suggests that current commercial vaccines might not effectively protect pigs from infection with a majority of H3N2 viruses.[40][41] The United States Department of Agriculture researchers say that while pig vaccination keeps pigs from getting sick, it does not block infection or shedding of the virus.[42]

Facility management includes using disinfectants and ambient temperature to control virus in the environment. The virus is unlikely to survive outside living cells for >2 wk except in cold (but above freezing) conditions, and it is readily inactivated by disinfectants.[1]

Herd management includes not adding pigs carrying influenza to herds that have not been exposed to the virus. The virus survives in healthy carrier pigs for up to 3 months and can be recovered from them between outbreaks. Carrier pigs are usually responsible for the introduction of SIV into previously uninfected herds and countries. After an outbreak, as immunity in exposed pigs wanes, new outbreaks of the same strain can occur.[1]

Prevention of transmission to humans

Swine can be infected by both avian and human influenza strains of influenza, and therefore are hosts where the antigenic shifts can occur that create new influenza strains.

The transmission from swine to human is believed to occur mainly in swine farms where farmers are in close contact with live pigs. Although strains of swine influenza are usually not able to infect humans this may occasionally happen, so farmers and veterinarians are encouraged to use a face mask when dealing with infected animals. The use of vaccines on swine to prevent their infection is a major method of limiting swine to human transmission. Risk factors that may contribute to swine-to-human transmission include smoking and not wearing gloves when working with sick animals.[43]

Prevention of spread in humans

Influenza spreads between humans through coughing or sneezing and people touching something with the virus on it and then touching their own nose or mouth.[44] Swine flu cannot be spread by pork products, since the virus is not transmitted through food.[44] The swine flu in humans is most contagious during the first five days of the illness although some people, most commonly children, can remain contagious for up to ten days. Diagnosis can be made by sending a specimen, collected during the first five days for analysis.[45]

Recommendations to prevent spread of the virus among humans include using standard infection control against influenza. This includes frequent washing of hands with soap and water or with alcohol-based hand sanitizers, especially after being out in public.[46] Although the current trivalent influenza vaccine is unlikely to provide protection against the new 2009 H1N1 strain,[47] vaccines against the new strain are being developed and could be ready as early as June 2009.[48]

Experts agree that hand-washing can help prevent viral infections, including ordinary influenza and the swine flu virus. Influenza can spread in coughs or sneezes, but an increasing body of evidence shows small droplets containing the virus can linger on tabletops, telephones and other surfaces and be transferred via the fingers to the mouth, nose or eyes. Alcohol-based gel or foam hand sanitizers work well to destroy viruses and bacteria. Anyone with flu-like symptoms such as a sudden fever, cough or muscle aches should stay away from work or public transportation and should see a doctor to be tested.

Social distancing is another tactic. It means staying away from other people who might be infected and can include avoiding large gatherings, spreading out a little at work, or perhaps staying home and lying low if an infection is spreading in a community. Public health and other responsible authorities have action plans which social distancing actions to request or require depending on the severity of the outbreak.

Treatment

In swine

As swine influenza is not usually fatal to pigs, little treatment is required; instead veterinary efforts are focused on preventing the spread of the virus throughout the farm, or to other farms.[14] Vaccination and animal management techniques are most important in these efforts.

In humans

If a person becomes sick with swine flu, antiviral drugs can make the illness milder and make the patient feel better faster. They may also prevent serious flu complications. For treatment, antiviral drugs work best if started soon after getting sick (within 2 days of symptoms). Beside antivirals, palliative care, at home or in the hospitals, focuses on controlling fevers and maintaining fluid balance. The U.S. Centers for Disease Control and Prevention recommends the use of Tamiflu (oseltamivir) or Relenza (zanamivir) for the treatment and/or prevention of infection with swine influenza viruses, however, the majority of people infected with the virus make a full recovery without requiring medical attention or antiviral drugs.[49] The virus isolates in the 2009 outbreak have been found resistant to amantadine and rimantadine.[50]

In the U.S., on April 27, 2009, the FDA issued Emergency Use Authorizations to make available Relenza and Tamiflu antiviral drugs to treat the swine influenza virus in cases for which they are currently unapproved. The agency issued these EUAs to allow treatment of patients younger than the current approval allows and to allow the widespread distribution of the drugs, including by non-licensed volunteers.[51]

Epidemiology

Swine flu has been reported numerous times as a zoonosis in humans, usually with limited distribution, rarely with a widespread distribution. Outbreaks in swine are common and cause significant economic losses in industry, primarily by causing stunting and extended time to market.

Notable outbreaks

A/Brevig-Mission/1918 (H1N1)

The 1918 flu pandemic in humans was associated with H1N1,[18] thus may reflect a zoonosis either from swine to humans or from humans to swine. Evidence available from that time is not sufficient to resolve this question. The "Spanish" influenza pandemic of 1918–19 infected one third of the world's population (or around 500 million persons at that time) and caused around 50 million deaths.[18]

2007 Philippine outbreak

On August 20, 2007 Department of Agriculture officers investigated the outbreak (epizootic) of swine flu in Nueva Ecija and Central Luzon, Philippines. The mortality rate is less than 10% for swine flu, unless there are complications like hog cholera. On July 27, 2007, the Philippine National Meat Inspection Service (NMIS) raised a hog cholera "red alert" warning over Metro Manila and 5 regions of Luzon after the disease spread to backyard pig farms in Bulacan and Pampanga, even if these tested negative for the swine flu virus.[52][53]

1976 U.S. outbreak

Main article: 1976 swine flu outbreak

On February 5, 1976, in the United States an army recruit at Fort Dix said he felt tired and weak. He died the next day and four of his fellow soldiers were later hospitalized. Two weeks after his death, health officials announced that the cause of death was a new strain of swine flu. The strain, a variant of H1N1, is known as A/New Jersey/1976 (H1N1). It was detected only from January 19 to February 9 and did not spread beyond Fort Dix.[54]

President Ford receives swine flu vaccination

This new strain appeared to be closely related to the strain involved in the 1918 flu pandemic. Moreover, the ensuing increased surveillance uncovered another strain in circulation in the U.S.: A/Victoria/75 (H3N2) spread simultaneously, also caused illness, and persisted until March.[54] Alarmed public-health officials decided action must be taken to head off another major pandemic, and urged President Gerald Ford that every person in the U.S. be vaccinated for the disease.[55]

The vaccination program was plagued by delays and public relations problems.[56] On October 1, 1976, the immunization program began and by October 11, approximately 40 million people, or about 24% of the population, had received swine flu immunizations. That same day, three senior citizens died soon after receiving their swine flu shots and there was a media outcry linking the deaths to the immunizations, despite the lack of positive proof. According to science writer Patrick Di Justo, however, by the time the truth was known — that the deaths were not proven to be related to the vaccine — it was too late. "The government had long feared mass panic about swine flu — now they feared mass panic about the swine flu vaccinations." This became a strong setback to the program.[21]

There were reports of Guillain-Barré syndrome, a paralyzing neuromuscular disorder, affecting some people who had received swine flu immunizations. This syndrome is a rare side-effect of modern influenza vaccines, with an incidence of about one case per million vaccinations.[57] As a result, Di Justo writes that "the public refused to trust a government-operated health program that killed old people and crippled young people." In total, less than 33 percent of the population had been immunized by the end of 1976. The National Influenza Immunization Program was effectively halted on Dec. 16.

Overall, about 500 cases of Guillain-Barré syndrome (GBS), resulting in death from severe pulmonary complications for 25 people, which, according to Dr. P. Haber, were probably caused by an immunopathological reaction to the 1976 vaccine. Other influenza vaccines have not been linked to GBS, though caution is advised for certain individuals, particularly those with a history of GBS.[58][59] Still, as observed by a participant in the immunization program, the vaccine killed more Americans than the disease did.[60]

1988 swine flu outbreak

In September 1988, a swine flu virus killed one woman in Wisconsin, and infected at least hundreds of others. 32-year old Barbara Ann Wieners was eight months pregnant when she and her husband, Ed, became ill after visiting the hog barn at the Walworth County Fair. Barbara died eight days later, though doctors were able to induce labor and deliver a healthy daughter before she passed away. Her husband recovered from his symptoms.

Influenza-like illnesses were reportedly widespread among the pigs at the fair they had visited, and 76% of the swine exhibitors there tested positive for the swine flu antibody but no serious illnesses were detected among this group. Additional studies suggested between one and three health care personnel who had contact with the patient developed mild influenza-like illnesses with antibody evidence of swine flu infection.[61][62]

See also

Wikimedia Commons has media related to Swine flu.

References

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Further reading

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