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Is H2H spread of H3N2v occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

So that's at least three separate cases in PA linked to the fair, and one likely H2H transmission in Indiana as the confirmed case did not have contact with swine, but had contact with someone who had contact with swine. Some degree of ongoing transmission of this virus seems likely. It would be interesting to know if the three cases from Washington County were at the fair at the same time, or if they even could have had contact with each other.

I'm not sure that this was even pig-to-human at the fair; these cases from Washington County, PA could have just as easily had contact with an ill human. No one seems to be making a big deal yet out of the fact that the first case announced Friday did not even live anywhere near the fair, and likely travelled while ill.

It also seems possible that these two latest cases may be more severe. We know they were supposedly infected before August 20, and they are reported to still be ill on September 5.

It is starting to feel like April 2009 all over again, although I still don't see any evidence of the cluster of unexplained severe ARI that might be expected at the start of a pandemic as was seen in Mexico City and Oaxaca, but that may be due to a milder virus or better detection capability in the US.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

From Emerging Infectious Diseases Journal: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876760/

Swine Influenza (H3N2) Infection in a Child and Possible Community Transmission, Canada

Joan L. Robinson,<SUP></SUP><SUP>*</SUP><SUP>?</SUP> Bonita E. Lee,<SUP>*</SUP> Jagdish Patel,<SUP>?</SUP> Nathalie Bastien,<SUP>?</SUP> Karen Grimsrud,<SUP>?</SUP> Robert F. Seal,<SUP>?</SUP> Robin King,<SUP>?</SUP> Frank Marshall,<SUP>#</SUP> and Yan Li<SUP>?</SUP><SUP>?</SUP>

(...)

The mode of spread of SIV in humans is not established. Because of his young age, the index patient was not likely to have had unrecognized direct contact with swine. That aerosolization of influenza virus occurs is increasingly recognized (25), but the child was reportedly never in the barns that housed the swine. However, other members of the farm reported that infants were sometimes taken for walks through the barn. The child also may have acquired the virus from person-to-person spread or from fomites. All 13 patients in the Fort Dix outbreak and 15 of 37 previously reported civilian case-patients also had no swine contact (19,20).
The Fort Dix outbreak of SIV in humans lasted only 21 days and never spread outside the military base. The calculated basic reproductive rate (R<SUB>0</SUB>) was only 1.1 to 1.2. This suggests that person-to-person spread of the implicated H1N1 strain was not efficient enough to produce a major epidemic (26). However, future strains of SIV could have a higher R<SUB>0</SUB>, and documentation of a case of swine influenza (H3N2) in a child with unrecognized transmission within the community adds another possible mechanism by which major epidemics of influenza could arise. Swine influenza infection in humans most commonly results in either no symptoms or a self-limited illness (6). However, routine surveillance for cases among swine workers may enable early detection of a strain with the potential for person-to-person transmission, prompting institution of infection control measures and vaccine development.

(...)

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Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Some sources are reporting that a sequence from a 9-year-old female, A/Pennsylvania/10/2011, has been deposited at GISAID with a collection date of July 27. The other two cases are given with sample collection dates of August 20 and 25.

Can we confirm this? If this is true, and not a typo, this case could not have attended the fair (August 13-20) because they would already have been ill for several weeks. Given that the CDC has repeatedly said that all three children attended the fair, and the case in Indiana had a collection date of July 27, I have to suspect this might be a typo...

Given the number "10" in the description A/Pennsylvania/10/2011 (the other two cases are "09" and "11"), perhaps the correct collection date should be between August 20 and 25?
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

I can confirm this is contained in the GISAID data base as of this time and date:

Isolate ID - EPI_ISL_96014

"9 year old female, A/Pennsylvania/10/2011, has been deposited at GISAID with a collection date of July 27." H3N2 SOIV with an M gene from 2009 H1N1 pandemic virus

Checking the rest......
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

There is also as of this time and date:

A/Pennsylvania/11/2011
Isolate ID - EPI_ISL_96013
9 year old female
Collection date: August 25, 2011
H3N2 SOIV - with an M gene from 2009 H1N1 pandemic virus

A/Pennsylvania/09/2011
Isolate ID - EPI_ISL_96012
2 year old female
Collection date: August 20, 2011
H3N2 SOIV - with an M gene from the 2009 H1N1 pandemic virus

A/Indiana/08/2011 (isolate from Pennsylvania area but defined at an Indiana lab)
Isolate ID - EPI_ISL_96015
2 year old male
Collection date: July 27, 2011
H3N2 SOIV - with an M gene from 2009 H1N1 pandemic virus

contained in the GISAID data base.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

sharon sanders said:
There is also as of this time and date:

\A/Indiana/08/2011 (isolate from Pennsylvania area but defined at an Indiana lab)
Isolate ID - EPI_ISL_96015
2 year old male
Collection date: July 27, 2011
H3N2 SOIV - with an M gene from 2009 H1N1 pandemic virus

contained in the GISAID data base.
Click to expand...

Does GISAID actually say this is an isolate from Pennsylvania defined at an Indiana lab? I thought this was the one "unlinked" case from Indiana from July, judging by the age, gender, and date...

The fact that this case and the suspiciously dated 9F (96014) have sequential GISAID numbering does aruge in favor of a typo in the collection date of that sample.

I'm not as alarmed by the August 25 sample collection date being 5 days after the fair. If one allows a few days incubation period and perhaps a week from onset to sample, an August 25 collection date could very well correspond to an expousre around August 15. It's that July 27 date that needs an explanation.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

There would also have to have been a typo in the case ID as well, right? One isolate collected on 7/27/11 is labeled A/Indiana/08/2011 (2M) and the other is labeled A/Pennsylvania/10/2011 (9F). There is also A/Pennsylvania/11/2011 (9F). So, if there was an error, it would have to be more than just the wrong date.

There is also the possibility that the child who was sick on July 27th attended the fair while still contagious and passed it on to others at the fair. I know it sounds far fetched, but if the virus has a longer-than-normal incubation period, it's possible.
alert said:
Does GISAID actually say this is an isolate from Pennsylvania defined at an Indiana lab? I thought this was the one "unlinked" case from Indiana from July, judging by the age, gender, and date...

The fact that this case and the suspiciously dated 9F (96014) have sequential GISAID numbering does aruge in favor of a typo in the collection date of that sample.
Click to expand...
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

We know there are two different cases in 96015 (2M) and 96014 (9F), both given as July 27 collection dates. The 2M is in Indiana, and the 9F is supposedly one of the fair-goers in Pennsylvania. What I suspect is the collection date of the 9F/96014 should be somewhere in late August or even early September, not July 27 as in the 2M. PA is admitting two different 9F's having gotten ill at the fair (the three PA cases are 2F, 9F, 9F), with the two 9F being #96014 and #96013. #96012/2F is the case that lived in Schuylkill County.

The 96015/2M is in Indiana and the CDC and PA DOH have both said they see no link between that and the PA cases (apart from what Sharon might have found at GISAID?).

The four sequences at GISAID do seem to me to correspond in age, gender, and location, to the four cases the CDC has announced, but I think one of the dates is wrong.
 
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Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Combining Sharon's GISAID data with the reporting elsewhere, I have the following list. I hope this helps clarify:

A/Pennsylvania/11/2011
Isolate ID - EPI_ISL_96013
9 year old female
Collection date: August 25, 2011
H3N2 SOIV - with an M gene from 2009 H1N1 pandemic virus
Attended fair in Washington County, PA
Lives in Washington County, PA
Still ill as of September 5, but recovering

A/Pennsylvania/09/2011
Isolate ID - EPI_ISL_96012
2 year old female
Collection date: August 20, 2011
H3N2 SOIV - with an M gene from the 2009 H1N1 pandemic virus
Attended fair in Washington County, PA
Lives in Schuylkill County, PA
Recovered prior to September 2.

A/Indiana/08/2011
Isolate ID - EPI_ISL_96015
2 year old male
Collection date: July 27, 2011
H3N2 SOIV - with an M gene from 2009 H1N1 pandemic virus
No known link to PA cases, location corrected to Indiana.
Contact with an individual who had contact with swine
Recovered prior to Spetember 2.

A/Pennsylvania/10/2011
Isolate ID - EPI_ISL_96014
"9 year old female
Sample collected on August 26 (originally errantly reported as July 27).
H3N2 SOIV with an M gene from 2009 H1N1 pandemic virus
Attended fair in Washington County, PA
Lives in Washington County, PA
Still ill as of September 5, but recovering
 
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Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Ok, I'm following you and the fact that there are two 9Fs in the group just confuses things further. Let's assume for a moment that the date is wrong. That means that there were one or more sick pigs at the fair. If all three trH3N2 cases were swine to human transmission only, then the virus must be acclimated to humans to such a degree that it appears transmission is possible with somewhat casual contact. I can't imagine that three different children (and likely more undocumented cases) spent a long time in close contact with the same infected animals.

I'm a visual learner and picture things in my mind as I work through them. I simply cannot picture a scenario where multiple children would catch the flu at a fair unless the virus was spreading H2H, or getting very close. If there is no efficient H2H transmission, then swine to human transmission appears to be very efficient.

If one also considers the amazing coincidence that would have to have occurred last season when novel trH3N2 was detected in a randomly selected sample sent for sequencing as part of routine surveillance, the circumstantial evidence is pointing towards H2H transmission that has been under way for some time. Perhaps the virus has traveled from swine to humans along multiple pathways, with some hitting a dead end (so to speak - forgive my amateur terminology) and others becoming more and more efficient.

alert said:
We know there are two different cases in 96015 (2M) and 96014 (9F), both given as July 27 collection dates. The 2M is in Indiana, and the 9F is supposedly one of the fair-goers in Pennsylvania. What I suspect is the collection date of the 9F/96014 should be somewhere around August 22, not July 27 as in the 2M. PA is admitting two different 9F's having gotten ill at the fair (the three PA cases are 2F, 9F, 9F), with the two 9F being #96014 and #96013. #96012/2F is the case that lived in Schuylkill County.

The 96015/2M is in Indiana and the CDC and PA DOH have both said they see no link between that and the PA cases (apart from what Sharon might have found at GISAID?).

The four sequences at GISAID do seem to me to correspond in age, gender, and location, to the four cases the CDC has announced, but I think one of the dates is wrong.
Click to expand...
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Combining this fair with the incident in Indiana (which certainly looks like at least one generation of H2H - pig to asymptomatic human to confirmed case), I suspect there is at least limited H2H going on here, but possibly not yet efficient H2H. Perhaps a Tamiflu blanket or some quarantines is warranted?

I find it odd that no article has mentioned yet the quarantine/isolation of any contacts of these cases.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

The GISAID EpiFlu database shows that the location for the sample A/Indiana/08/2011 is Pennsylvania.

The originating lab for this sample was Indiana State Department of Health Laboratories.

----------------------

As to A/Pennsylvania/10/2011 (from a 9 year old female), I checked again and the GISAID database indicates a collection date of July 27, 2011. The sample ID given by the origination lab which is the Pennsylvania Dept of Health is M11021660 ORIGINAL. CDC sample ID 2011815127

The other isolate from a 9 year old female A/Pennsylvania/11/2011 sample ID given by the originating lab which is University of Pittsburgh Medical Center Microbiology Lab is K. ORIGINAL. CDC sample ID 2011811782

These are 2 different isolates.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

sharon sanders said:
The GISAID EpiFlu database shows that the location for the sample A/Indiana/08/2011 is Pennsylvania.

The originating lab for this sample was Indiana State Department of Health Laboratories.

----------------------

As to A/Pennsylvania/10/2011 (from a 9 year old female), I checked again and the GISAID database indicates a collection date of July 27, 2011. The sample ID given by the origination lab which is the Pennsylvania Dept of Health is M11021660 ORIGINAL. CDC sample ID 2011815127

The other isolate from a 9 year old female A/Pennsylvania/11/2011 sample ID given by the originating lab which is University of Pittsburgh Medical Center Microbiology Lab is K. ORIGINAL. CDC sample ID 2011811782

These are 2 different isolates.
Click to expand...

OK. That's very interesting. So the "Indiana" case reported in the MMWR may actually have a link to Pennsylvania, perhaps even to Washington County, although unlikely to the fair given the reported date. Does it say where in Pennsylvania the sample was collected? I wonder why that information has not been clearly released. All the Pennsylvania cases announced publicly are female. I think this must be the case from "Indiana" in the MMWR because the age and collection date match. It seems really unlikely that they would have wrongly reported the collection location here (or lied in the MMWR?), but that is the only thing I can think of. This one really makes no sense. Could this represent yet another unreported case?

It seems obvious that two of the other Pennsylvania cases are 9F's. What is not clear, IMO, is whether the reported collection date is correct for the first 9F. It is not the other 9F that I think they might have confused the testing date with; I think they may have duplicated the date of the "Indiana" 2M.

At this point, the data at GISAID is not even close to consistent with the MMWR or PA DOH reports. There seem to be at least the two discrepancies above. As a Pennsylvanian, this is downright embarrassing. Just get the information right.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Alert, could you make a note beside the Indiana case that the collection location was Pennsylvania?

It's easy to speculate at this point that the Indiana case was visiting in Pa during that time.

I agree that the July collection date may be a mistake. Since Pa/09 was collected on 8-20 and Pa/11 was collected on 8-25, it seems a bit odd for Pa/10 to be collected a whole month earlier.

OR, the two July cases must have been to some fair other than the Washington County fair. I see the Bedford fair ran July 22-28 and they had swine judging on the 25th; plus they had a petting zoo. http://www.bedford-fair.com/schedule.htm

The CDC needs to confirm the dates.
 
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Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

It seems odd to me that there are no health notices from Indiana. If the "Indiana" trH3N2 case was truly from Indiana then there would be a notice from the state health department similar to the one issued by Pennsylvania (Pennsylvania Department of Health - Questions & Answers: Novel Influenza A Virus)

In addition, there is noting about trH3N2 on the Indiana State Department of Health web site: http://www.in.gov/isdh/

And, I find nothing in any Indiana newspapers about a local case of trH3N2.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

OK, mixin, I have updated my above list to indicate that, and put it in underlined red text as a second discrepancy.

The MMWR says the Indiana case had contact with someone who had contact with swine. If the contact or the swine was in PA, I would have thought the MMWR would mention it (although that would explain why I don't see any evidence of ongoing investigation in Indiana as is occurring in PA). The Indiana case is far too early (onset 7/23) to have been exposed to anything else reported in PA, even if that other case was collected 7/27 (which it really couldn't be).

The MMWR states:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e0902a1.htm

No direct exposure to swine was identified for this child; however, a caretaker reported direct contact with asymptomatic swine in the weeks before the boy's illness onset and provided care to the child 2 days before illness onset. No respiratory illness was identified in any of the child's family or close contacts, the boy's caretaker, or in the family or contacts of the caretaker.

Was the caregiver an asymptomatic infection? Could this all have happened in PA?

I await either changes to the GISAID data (if it contains two errors) or announcement of additional cases (if the MMWR is incomplete/incorrect).
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Thanks Alert.

I edited this into my other post: I see the Bedford fair ran July 22-28 and they had swine judging on the 25th; plus they had a petting zoo. http://www.bedford-fair.com/schedule.htm

Maybe there was just some confusion as to which fair she attended?
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Bedford is about 100 miles from Washington; if there were infected pigs at a second fair, this virus would be pretty widespread in pigs. As yet, not a single pig has tested positive for this virus.

But if a few infected, asymptomatic swine were in Washington County since at least early July, I could imagine the caretaker could have had contact with the pigs, been asymptomatically infected, and passed the virus to the "Indiana" infant. What is still odd about this story is that the infant was hospitalized without suspicion of swine flu; it was only retrospective testing that found it on August 17.

I'm pretty sure the date on the 9F is a reporting error (enough sources have put her at the Washington County fair), but the relationship of the "Indiana" case to Washington County needs to be explained. One of the PA cases (Schuylkill County) apparently travelled about 200 miles after being infected before taking ill. Is that was happened in Indiana as well? If this 2M or his caretaker was in Washington County, I would have expected the CDC to report that, even if they did not have contact with any of the PA cases.
 
Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Re: Is H2H spread of a novel swine H3N2 occurring in the United States?

Here's the Indiana case... he was ill on July 23. Notice the specimen was forwarded but it doesn't say from where.

Patient A. On August 17, 2011, CDC was notified by the Indiana State Department of Health Laboratories of a suspected case of swine-origin influenza A (H3N2) infection in a boy aged <5 years. The boy, who had received influenza vaccine in September 2010, experienced onset of fever, cough, shortness of breath, diarrhea, and sore throat on July 23, 2011. He was brought to a local emergency department (ED) where a respiratory specimen later tested positive for influenza A (H3). The boy was discharged home, but was not treated with influenza antiviral medications. He has multiple chronic health conditions, returned to the ED on July 24, 2011, and was hospitalized for treatment of those health problems, which had worsened. The boy was discharged home on July 27, 2011, and has since recovered from this illness. As part of routine CDC-supported influenza surveillance, the respiratory specimen collected on July 24, 2011, was forwarded to the Indiana State Department of Health Laboratories, where polymerase chain reaction (PCR) testing identified a suspect swine-origin influenza A (H3N2) virus on August 17, 2011. The specimen was forwarded to CDC where the findings were confirmed through genome sequencing on August 19, 2011.

No direct exposure to swine was identified for this child; however, a caretaker reported direct contact with asymptomatic swine in the weeks before the boy's illness onset and provided care to the child 2 days before illness onset. No respiratory illness was identified in any of the child's family or close contacts, the boy's caretaker, or in the family or contacts of the caretaker.
 
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