In this video, Dr. Joe Bresee, with CDC’s Influenza Division, describes the symptoms of swine flu and warning signs to look for that indicate the need for urgent medical attention.
What are the symptoms of swine influenza?
The symptoms of swine influenza in people are similar to the symptoms of common human seasonal influenza infection and include fever, fatigue, lack of appetite, coughing and sore throat. Some people with swine flu have also reported vomiting and diarrhoea.
Swine flu is only diagnosed currently with a fever (or fever history) and flu symptoms and travel (within 7 days) to Mexico or parts of the US and Canada. This remains unlikely for most people.
If someone who has been to affected areas is feeling sick what should they do?
Follow the guidance issued to each household this week and call the NHS helpline or local NHS direct. People are advised NOT to go to their GP but to stay indoors and get a ‘Flu Friend’ to do the running around for them.
Anyone who has recently travelled to the affected areas and is experiencing influenza-like illness should stay at home to limit contact with others, and seek medical advice from a local health professional or by contacting NHS Direct on 0845 46 47. Anyone returning from infected areas who is otherwise well should contact Occupational Health through their line manager for advice on returning to work. Most people will be fit for work if they are feeling well and have not come into contact with anyone proven to have caught Influenza type A H1N1(Swine Flu).
Is treatment available?
Testing has shown that the effect of the human influenza H1N1 can be modified with the antiviral medication. Most of the previously reported swine influenza cases recovered fully from the disease with simple medical attention and antiviral medicines.
The UK is well prepared with pandemic action plans, flu vaccination and antiviral stocks.
Is this swine flu virus contagious?
It has been determined that this virus is contagious and it spreads between people, although it is not known how easily. Cases in the UK have been mild and many suspected cases have proven negative so far. The public are being advised to follow the advice in the leaflet distributed to all households (wc 11 May 2009).
How common are cases of swine influenza?
Cases of swine influenza in humans initially occured after direct or close contact with infected pigs. The person-to-person transmission has now been reported and is the main method of spread to humans. However, the number of cases in the UK is still small at the moment and the symptoms in most cases are mild.
What measures can I take to protect against infection?
Advice is given in the leaflet distributed to all households (wc 11 May 2009). General infection control practices and good respiratory hand hygiene can help to reduce transmission of all viruses, including the human swine influenza. This includes:
- Covering your nose and mouth when coughing or sneezing, using a tissue when possible
- Disposing of dirty tissues promptly and carefully
- Maintaining good basic hygiene, for example washing hands frequently with soap and water to reduce the spread of the virus from your hands to face or to other people
- Cleaning hard surfaces (e.g. door handles) frequently using a normal cleaning product
- Making sure your children follow this advice
What level of alert have we reached and what does this mean?
The World Health Organization (WHO) raised its pandemic alert level to Phase 5 on Tuesday 29 April 2009. The Director-General of WHO is the decision maker in terms of elevating the global stages of pandemic alert. Experts from around the world are working in close collaboration with WHO to help determine what risk this situation poses to global public health.
The current phase 5 is characterised by consistent ‘human-to-human’ spread of the virus in at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a severe pandemic could be imminent and that the time to finalise the organisation, communication and implementation of the planned mitigation measures is short.
Equally this does not mean that a severe pandemic will definitely occur or define its severity.
What is the difference between seasonal influenza, avian influenza, swine influenza and an influenza pandemic?
Influenza viruses are commonly circulating in the human and animal environment. Different strains can cause illness in humans, bird and pigs.
Seasonal influenza is caused by influenza viruses that are adapted to spread between humans (human influenza). Humans have some natural immunity to the strains that are in common circulation, and this immunity can be boosted by immunisation with a seasonal influenza vaccine.
Avian influenza is caused by influenza viruses adapted for infection in birds. Similarly, swine influenza is caused by influenza viruses adapted for infection in pigs. These illnesses all elicit the same respiratory symptoms in their hosts. Sometimes, humans and animals can pass strains of influenza back and forth to one another, such as when humans become ill with avian or swine influenza, usually from direct contact with animals who are ill.
Mixing of human and animal influenza viruses can lead to the development of changed viruses with the ability to cause infection and spread in the human population. There may be little or no immunity in the human population to these new viruses.
An influenza pandemic is defined as a new or novel influenza virus that spreads easily between humans. When new influenza viruses are introduced into the environment, humans don’t have any natural immunity to protect against them. Therefore, there is a risk that that new influenza viruses could develop into a pandemic if the newly adapted virus starts to pass easily from human to human.
Can I catch Swine Flu from pork products?
People will not get swine flu from eating pork or pork products
It is important to stress that swine influenza viruses are not transmitted by food. There is no risk of catching the illness from eating properly handled and cooked pork or pork products.
Can I do anything to prepare?
Sensible personal steps might include thinking about;
- Emergency contact numbers for medical services
- Ordering repeat prescriptions if you have a pre-existing medical condition
- Avoiding large public gatherings
- Thinking about what strain on national infrastructure might mean for you and your family
- Increased hygiene measures and infection prevention measures at home and at work.
How is this likely to develop? Will it come back?
Clinical professionals are tracking the numbers of cases being tested and confirmed diagnoses. The virus is not spreading as fast or with the severity that was first predicted in Mexico. It is important that the UK maintains its state of planning should the virus change or cases rise with seasonal influenza in the Autumn.
When did Nuffield Health start mobilising for a pandemic?
Nuffield Health has prepared fully for this event over the past 3 years through our clinical and occupational health teams to ensure we have prudent business plans in place for pandemic flu which fits into our Group approach to crisis management.
What is Nuffield Health doing currently?
We are prepared as a business. In essence, we are following the HPA guidance and working closely with local PCTs.
A pandemic influenza team is leading our business continuity plans with regular meetings and communication to our hospitals and centres as things develop internationally. The team is being led by the Group Medical Director supported by an external consultant microbiologist. Nuffield Health holds good stocks of antiviral and antibacterial medication and infection prevention equipment, our staff have been highly trained in infection prevention procedures. We are in regular contact with local and national public organisations coordinating influenza planning.
At what point will Nuffield Health start treating people for swine flu?
When they meet the criteria as outlined by the HPA for treatment (includes actual & prophylactic treatment).
What has and is happening to us, our patients and customers?
At present, as an organisation, we are in a planning phase. Services to patients and customers have not been directly affected although information is exchanged on a daily basis with our 200 business units and we have recommended to our staff and customers that now is the right opportunity to familiarise themselves with national procedures and policies.
What trends is Nuffield Health seeing?
Nationally the trend has been one of mild illness with no real impact on day to day activities for the average person and in the UK we are not seeing the number of deaths feared at the beginning.
Is Nuffield Health in communication with the HPA / DH? If so, to what level?
Yes, via our Group Consultant Microbiologist & Group Medical Director who both do work for and have contact with the Department. Our Occupational Health manager has been part of the DH pandemic flu planning committee.
Is Nuffield Health helping local PCTs deal with swine flu? If so, how?
All hospitals are involved in their local emergency planning teams that are PCT co-ordinated.
If a pandemic does become reality and deaths occur all healthcare facilities will work together to assist with public health and business continuity.
If a pandemic does become reality and deaths occur, the HPA have the power to commandeer our hospitals and staff for whatever purpose they see fit.
Where does Nuffield Health stand now with regard to the development of a possible pandemic?
We stand concerned that there will be a second wave in the Autumn that will be more virulent (stronger and more likely to kill).
Is the organization less or more nervous than before?
Nuffield Health is well prepared for any escalation in the present situation but overall we are probably not as nervous as at the outset although we are aware that things may change in the Autumn.
How well do you think the Government / authorities have performed?
As well as can be expected and rapidly in response to developments – this is new to all of us worldwide but internationally it is very joined up and efficient.
Do you think the threat of a pandemic has been overstated by the authorities/media?
At present the trend appears to be one of mild illness with no real impact and the number of deaths in the UK is not as many as had been feared. However, it is better to plan for the worst and hope for the best and Nuffield Health is taking the prudent approach and planning for all eventualities. It’s all too easy to judge with hindsight but no-one knows for certain how things will develop. The public is being given information and practical advice from the relevant authorities.
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. 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. 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.
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. 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, so new animals should be quarantined. After an outbreak, as immunity in exposed pigs wanes, new outbreaks of the same strain can occur.
Prevention in humans
Prevention of pig 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.
Prevention of human to human transmission
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. Swine flu cannot be spread by pork products, since the virus is not transmitted through food. 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.
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. Although the current trivalent influenza vaccine is unlikely to provide protection against the new 2009 H1N1 strain, vaccines against the new strain are being developed and could be ready as early as June 2009.
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 contact 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.
In pigs influenza infection produces fever, lethargy, sneezing, coughing, difficulty breathing and decreased appetite. In some cases the infection can cause abortion. Although mortality is usually low (around 1-4%),the virus can produce weight loss and poor growth, causing economic loss to farmers. Infected pigs can lose up to 12 pounds of body weight over a 3 to 4 week period.
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 since the first report in the medical literature in 1958, which have resulted in a total of six deaths. Of these six people, one was pregnant, one had leukemia, one had Hodgkin disease and two were known to be previously healthy. Despite these apparently low numbers of infections, the true rate of infection may be higher, since most cases only cause a very mild disease, and will probably never be reported or diagnosed.
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. 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.” A diagnosis of confirmed swine flu requires laboratory testing of a respiratory sample (a simple nose and throat swab).
Transmission between pigs
The main route of transmission is through direct contact between infected and uninfected animals. 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. The virus usually spreads quickly through a herd, infecting all the pigs within just a few days. Transmission may also occur through wild animals, such wild boar, which can spread the disease between farms.
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. 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. 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.
Transmission to humans usually does not result in influenza in humans. When it does result in influenza, usually the influenza is mild and the basic reproduction number of the virus in human hosts is low enough that an outbreak does not occur.
Of the three genera of influenza viruses that cause human flu, two also cause influenza in pigs, with Influenza virus A being common in pigs and Influenza virus C being rare. Influenza virus 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 viruses infect both humans and pigs, but do not infect birds. Transmission between pigs and humans have occurred in the past. For example, influenza C caused a small outbreaks of a mild form of influenza amongst children in Japan, and California. 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.
Swine influenza is known to be caused by influenza A subtypes H1N1, H1N2, H3N1, H3N2 and H2N3. In pigs, three influenza A virus subtypes (H1N1, H3N2, and H1N2) are the most common strains worldwide. 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.
A/Veracruz/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.
Swine influenza (also called swine flu, pigfluenza, hog flu, and pig flu) refers to influenza caused by those strains of influenza virus that usually infect pigs and are called swine influenza virus (SIV). Swine influenza 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, Mainland China, Taiwan, Japan and other parts of eastern Asia.
Transmission of swine influenza virus from pigs to humans is not common. When transmitted, it does not always cause human influenza and often, the only sign of infection is the presence of antibodies which are only detectable by laboratory tests. When transmission results in influenza in a human, it is called zoonotic swine flu. People who work with pigs, especially people with intense exposures, are at risk of catching swine flu. However, only about fifty such transmissions have been recorded since the mid-20th Century, when identification of influenza subtypes became possible. (Importantly, eating pork does not pose a risk of infection.) Rarely, these strains of swine flu can pass 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 an apparently virulent 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. The origin of this new strain is unknown, and the World Organization for Animal Health (OIE) reports that this strain has not been isolated in pigs. It passes with apparent ease from human to human, an ability attributed to an as-yet unidentified mutation. This 2009 H1N1 strain causes the normal symptoms of influenza, such as fever, coughing and headache.