1. Not Yet….

2. Novel Human Swine Flu Event Texas 2008 Neil Pascoe DSHS Matt Cochran TAHC

3. Program Swine flu investigation 2008 Discuss Pandemic Influenza Novel H1N1-2009 (Swine Flu)

4. But first a message from our sponsor

5. Texas Human Swine Influenza Case

6. First Notification 11/3/08 3:21 PM Just a heads up. We sent specimen AVI0800070 to CDC on Thursday of last week. It was positive for FLU A but thus far, we have not been able to subtype it. CDC is running additional tests to determine if this is a "true" unsubtypeable Flu A. I expect to hear from CDC tomorrow. And FYI, this could be a reagent issue, but we should know more tomorrow. Thanks - martha –Martha Thompson, MPH –Viral Isolation Team Leader

7. Case 14 YO male, Gr. 9 HS student Hx of asthma otherwise healthy Onset Tuesday 10/14/08 F/ST/cough sent home from school Presented 10/15/08 local OP clinic Fever 103F Cough, HA, sore throat, conjunctivitis, diarrhea flu vaccination 2008 (according to mother)

8. Household Parents and 2 siblings –Brother 12 yo 7 th grade –Sister 6 years, 1 st grade No one else ill Cats, dogs, goats, pigs Case raises show pigs and recently purchased pigs the previous weekend

9. Investigation Flu study conducted in Bell County (reason for culture) Early in flu season but no increase in ILI School surveillance showed no increase in absenteeism Specimen collected 10/15 sent to DSHS 10/24 (for routine subtyping) and to the CDC on 10/30 Serum collected 11/6 from all family members sent to CDC (preliminary results are neg.)

11. Texas Swine Influenza Case October 11 th, 2008 visited: –Plainview, ‘Ring of Success Pig Sale’ (purchased pig) This pig originated in Nebraska This pig had a “light cough” when purchased and a “light rash” and was “lethargic” – new owners attributed the rash to the hay bedding and treated with benadryl, and treated the cough with Nuflor (Florfenicol) October 12 th, 2008 visited: – Comfort Texas (purchased 2 pigs) October 14 th, 2008 –Onset of clinical signs in 14 year old boy

12. Travis County DSHS Central Office Hale County Pig Purchased 10/11/08 Bell County Case and S&W Kendall County 2 pigs bought 10/12/08 You are here

13. Texas Swine Influenza Case ‘Case pig owners’ contacted by TAHC on 11/4/2008 Sick pig was purchased at ‘Ring of Success Pig Sale’ in Plainview Texas Pig was not consigned to the sale, but sold under private treaty off the trailer in the parking lot outside the sale Seller had ~60 pigs for sale Pig was transported home on a trailer with several other pigs originating from various sources and belonging to various owners –A third party hauler

14. Investigation Participants Bell County HD –Angi Bridges, CDC –Lyn Finelli, Lenee Blanton, Steve Lindstrom, Tom Gomez et al DSHS –Martha Thompson and lab, Neil Pascoe, Russ Jones, others NVLS –Sabrina Swenson, Beverly Schmitt, others TAHC –Andy Schwartz, Tommy Barton, Dee Ellis, Matt Cochran, others

15. Pandemic Influenza: When the Swine Flu Hits the Fan?

16. Influenza A Only flu A has subtypes 3 main subtypes have been identified with the majority of human disease (H1, H2, H3) Potential for tremendous genetic diversity Only flu A causes pandemics

17. Human Influenza Taxonomy A (H1N1)/New Caledonia/20/99 Type subtype Geographic strain year of origin number isolation (often referred to as strain) Non human species will be described A(species)(H1N7)/Austin/325/2005

18. Hemagglutinin Membrane protein that binds to cell surface receptors 16 different subtypes exist (1-16) Only H1, H2, and H3 have circulated in humans in the last century

19. Neuraminidase 9 different subtypes (1-9) Responsible for penetration of epithelial cell wall- replication Only N1 and N2 have circulated in humans in the past century

20. Antigenic Drift Only Flu A Responsible for yearly influenza activity Point mutations resulting after errors in RNA dependent RNA polymerase (3.6 x 10 –3 nucleotide changes/nucleotide site/year for hemagglutinin protein of influenza A as opposed to 1.6 in influenza B) Same subtype-H3N2 (Panama, Fujian, Korea)

21. Antigenic Shift Results in novel subtype (H5N1, H9N2, H7N3) Responsible for pandemics Facilitated by segmented genome and large reservoir of different influenza A HA and NA subtypes in wild birds

22. Pandemic Influenza Global outbreak of a new subtype of influenza to which virtually no one is immune –Novel subtype (strain) –Susceptible population –Virulent –Transmissible person to person Emergence of a novel strain can occur via: –Radical change in virus already infecting humans –Change in virus previously only seen in animals that allows it to infect humans

23. Recorded Influenza Pandemics

27. USS Pandemic Flu

28. First Case of Human Infection with SIV, San Diego, California March 30: 10 year old male developed fever, cough, vomiting Seen in urgent care clinic NP swab collected April 13, 2009, CDC notified of 10 year old boy with respiratory illness from California Unsubtypeable influenza A virus identified from specimen at clinic April 14: Specimen received by CDC and swine influenza A (H1N1) virus identified Public health laboratory testing for human influenza A subtypes was negative

29. First Case of Human Infection with SIV, Imperial County, California March 28: 9 year old female developed cough and fever Seen at clinic NP swab collected April 17, 2009, CDC received unsubtypeable influenza A virus specimen from Naval Health Research Center (NHRC), San Diego NHRC identified virus as unsubtypeable influenza A with possible swine origin April 17: Specimen received by CDC and identified as swine influenza A (H1N1) virus

30. Confirmed Cases of Human Infection with SIV Number of Confirmed Cases Case Patient A Flew to Dallas, Texas No known epidemiologic link between the Texas and California cases

31. Analysis of Texas Confirmed H1N1 Case Summary As of 5/27/2009 at 10:00AM The case summary is produced as analysis is complete. It may not include all cases and may not match CDC’s case numbers.

32. Demographics* DemographicN% Sex846 – Male41249% – Female43451% Age (median 10 yrs, range 1 mos – 84 yrs) 863 – <5 years13616% – 5-18 years55765% – 19-45 years13215% – >45 years384% *Based on confirmed cases for whom these data are available at time of report

33. Additional Data on Confirmed Cases* Vaccinated within the last year for seasonal influenza –34% (74 of 217) of children ≤18 years old –26% (10 of 38) of people >18 years old 8% (21 of 274) with recent travel to Mexico 14 Cases were hospitalized (1 from Mexico) –4 required ICU care –6 deaths have been confirmed (as of 6/2/09) *Based on confirmed cases for whom these data are available at time of report

34. Signs and Symptoms NSymptomati c % Fever (>100ºF) (median temp: 102.0ºF) 24823093% Sore throat 28316960% Cough 31327287% GI symptoms (diarrhea and/or vomiting) 2069647% Met Influenza Like Illness (ILI) case definition (fever and sore throat or cough) 21618787% *Based on confirmed cases for whom these data are available at time of report

35. Rapid Testing Data for Confirmed Cases as of 5/27/2009 10:00am Rapid flu test results available for 218 confirmed cases –92% (201 of 218) positive for Flu A –4% (9 of 218) positive flu undifferentiated –4% (8 of 218) negative