Mitigating Zoonotic Disease Transmission Among Youth Participating in Agricultural Exhibitions

Mitigating zoonotic disease transmission among youth participating in agricultural exhibitions

DISSERTATION

Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University

Jacqueline M. Nolting

Graduate Program in Agricultural and Extension Education

The Ohio State University

2018

Dissertation Committee:

Dr. Scott Scheer - Advisor Dr. Armando Hoet Dr. Jeffrey King Dr. M. Susie Whittington

Copyrighted by

Jacqueline Michele Nolting

2018

Abstract

Educating youth regarding the risk of zoonotic disease is an important animal and public health concern as nearly three out five new human illnesses are zoonotic. In addition, disease prevention was determined to be the life skill least represented in 4-H youth development programming, making this an important addition to youth programs.

Justification for increased diligence in this area is highlighted by the continual cases of reported zoonotic transmission of influenza A viruses between pigs and people, which has received considerable publicity following the H3N2 variant influenza A virus

(H3N2v) outbreaks of 2011-2017. Most cases of H3N2v reported have been in youth swine exhibitors associated with agricultural fairs. Building a repertoire of mitigation strategies based on scientific evidence is a key component to the development of sustainable educational programming because it provides a means by which exhibitors can be a part of the solution. Leading transitions is impossible without evidence to support the proposed behavioral changes; therefore data collected from the studies conducted at The Ohio State University have been used to develop a multi-faceted educational program to educate youth on the risk associated with zoonotic disease.

Youth involved in swine exhibition are unaware of the risk posed by influenza A viruses, and other zoonotic diseases, that are transmitted between swine and humans. As a result, management practices to prevent transmission events are not being followed and each year humans become infected with influenza A viruses from exposure to exhibition ii

swine. Educating youth about the risks associated and potential mitigation strategies to lessen those risks is being initiated to protect human and animal health. As a result the following research questions were developed. 1) How do youth swine exhibitors‟ knowledge about IAVs change when participating in scenario-based training exercises?

2) What predictor variables determine IAV knowledge through scenario-based training exercises? 3) Has the dissemination of the “Swine Zoonotic Disease Risks and

Prevention” chapter of the Swine Resource Handbook been effective? 4) How did the

“Becoming a Swientist” Program influence the healthy habits of swine exhibitors? 5)

What were the perceptions and behaviors of jackpot swine exhibitors related to IAV?

Mixed methods were used to evaluate these questions which resulted in significant gains in knowledge and the adoption of healthy habit behaviors. In addition, perceptions and behaviors of jackpot showmen were observed using a survey to determine the effectiveness of recommendations included in the “Measures to Minimize Influenza

Transmission at Swine Exhibitions” document. This study provides evidence that developing and disseminating static recommendations to reduce zoonotic disease transmission is not enough to change human behavior and interactive methods must be deployed to prevent future variant IAV infections associated with swine exhibitions.

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Dedication

Dedicated to Eric and Alex; may you always chase your dreams.

To leave the world a bit better, whether by a healthy child, a garden path, or a redeemed social condition; to know even one life breathed easier because you lived. This is to have succeeded. – attributed to Ralph Waldo Emerson

Acknowledgments

I express sincere gratitude to Andy Bowman and the entire Animal Influenza

Ecology and Epidemiology Research Program team for their tremendous support and effort to initiate these educational programs. I would also like to graciously thank extension educators from the five participating counties for their cooperation and assistance with the organization and execution of training sessions. This work was funded by Council for State and Territorial Epidemiologists under contract number [PREV-

31299] in collaboration with federal funds from the Centers of Excellence for Influenza

Research and Surveillance (CEIRS), National Institute of Allergy and Infectious Diseases,

National Institutes of Health, Department of Health and Human Services, under Contract No.

[HHSN272201400006C].

Vita

Education

2008 M.S. The Ohio State University, Major: Veterinary Preventive Medicine

2005 B.S. The Ohio State University, Major: Animal Science

Positions and Employment 2014-present Clinical Laboratory Manager, Veterinary Preventive Medicine, The Ohio

State University

2012-2015 Adjunct Instructor, Columbus State Community College

2011- 2015 Adjunct Instructor, Central Ohio Technical College

2010-2014 Research Associtate, Veterinary Preventive Medicine, The Ohio State

University

2005-2010 Research Assistant, Veterinary Preventive Medicine, The Ohio State

University

Awards

SEEDS: The OARDC Research Enhancement Competitive Grant for Graduate Students.

Project entiteled “Prescence of influenza A viruses in poultry and waterfowl at Ohio agricultual fairs.

Publications

1. Nolting JM, Midla J, Whittington MS, Scheer SD, Bowman AS. Educating youth swine exhibitors on influenza A virus transmission at agricultural fairs. Zoonoses and Public Health. 2017;00:1–5. https://doi.org/10.1111/zph.12422 2. Nolting JM, Fries AC, Gates RJ, Bowman AS, Slemons RD, "Influenza A viruses from over-wintering and spring-migrating waterfowl in the Lake Erie Basin, United States". Avian Diseases. (In Press) 3. Elizabeth Bailey, Li-Ping Long, Nan Zhao, Jeff Hall, John A. Baroch, Jacqueline Nolting, Lucy Senter, Frederick L. Cunningham, G. Todd Pharr, Larry Hanson, Richard Slemons, Thomas J. DeLiberto, and Xiu-Feng Wan, (2017) "Antigenic Characterization of H3 Subtypes of Avian Influenza A Viruses in North America". Avian Diseases. 4. Bowman AS, Nolting JM, Workman JD, Cooper M, Fisher AE, Marsh BM, Forshey T, "The inability to screen exhibition swine for influenza A virus using body temperature.” Zoonoses and Public Health. (In Press) 5. Runstadler,J,A; Happ,G,M; Slemons,R,D; Sheng,Z-M; GUNDLACH,N; Petrula,M; Senne,D; Nolting,J; Evers,D,L; Modrell,A; Huson,H; Hills,S; Rothe,T; Marr,T; Taubenberger,J,K, "Using RRT-PCR analysis and virus isolation to determine the prevalence of avian influenza virus infections in ducks at Minto Flats State Game Refuge, Alaska, during August 2005". (2007) Archives of Virology. Vol. 152, no. 10: 1901-1910. 6. Dugan,Vivien,G; Chen,Rubing; Spiro,David,J; Sengamalay,Naomi; Zaborsky,Jennifer; Ghedin,Elodie; Nolting,Jacqueline; Swayne,David,E; Runstadler,Jonathan,A; Happ,George,M; Senne,Dennis,A; Wang,Ruixue; Slemons,Richard,D; Holmes,Edward,C; Taubenberger,Jeffery,K, "The evolutionary genetics and emergence of avian influenza viruses in wild birds".(2008) PLOS Pathogen. Vol. 4, no. 5: e1000076. 7. Dugan,Vivien,G; Dunham,Eleca,J; Jin,Guozhong; Sheng,Zong-mei; Kaser,Emilee; Nolting,Jacqueline,M; Alexander,H,Lloyd; Slemons,Richard,D; Taubenberger,Jeffery,K, "Phylogenetic analysis of low pathogenicity H5N1 and H7N3 influenza A virus isolates recovered from sentinel, free flying, wild mallards at one study site during 2006". (2011) Virology. Vol. 417, no. 1: 98-105. 8. Bowman,Andrew,S; Sreevatsan,Srinand; Killian,Mary,L; Page,Shannon,L; Nelson,Sarah,W; Nolting,Jacqueline,M; Cardona,Carol; Slemons,Richard,D, "Molecular evidence for interspecies transmission of H3N2pM/H3N2v influenza A

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viruses at an Ohio agricultural fair, July 2012". (2012) Emerging Microbes & Infections. Vol. 1, e33. 9. Bowman,Andrew,S; Nolting,Jacqueline,M; Nelson,Sarah,W; Slemons,Richard,D, "Subclinical influenza virus A infections in pigs exhibited at agricultural fairs, Ohio, USA, 2009-2011." (2012) Emerging infectious diseases. Vol. 18, no. 12: 1945-1950. 10. Nolting,Jacqueline; Fries,Anthony,C; Slemons,Richard,D; Courtney,Chad; Hines,Nichole; Pedersen,Janice, "Recovery of H14 influenza A virus isolates from sea ducks in the Western Hemisphere." (2012) PLoS currents. Vol. 4, RRN1290-?. 11. Bowman,Andrew,S; Nelson,Sarah,W; Edwards,Jody,L; Hofer,Christian,C; Nolting,Jacqueline,M; Davis,Ian,C; Slemons,Richard,D, "Comparative effectiveness of isolation techniques for contemporary Influenza A virus strains circulating in exhibition swine" (2013) Journal of Veterinary Diagnostic Investigation . Vol. 25, no. 1: 82-90. 12. Fries,Anthony,C; Nolting,Jacqueline,M; Danner,Angela; Webster,Robert,G; Bowman,Andrew,S; Krauss,Scott; Slemons,Richard,D, "Evidence for the Circulation and Inter-Hemispheric Movement of the H14 Subtype Influenza A Virus"(2013) PLOS ONE. Vol. 8, no. 3: e59216. 13. Feng,Zhixin; Gomez,Janet; Bowman,Andrew,S; Ye,Jianqiang; Long,Li-Ping; Nelson,Sarah,W; Yang,Jialiang; Martin,Brigitte; Jia,Kun; Nolting,Jacqueline,M; Cunningham,Fred; Cardona,Carol; Zhang,Jianqiang; Yoon,Kyoung-Jin; Slemons,Richard,D; Wan,Xiu-Feng, "Antigenic Characterization of H3N2 Influenza A Viruses from Ohio Agricultural Fairs"(2013) Journal of Virology. Vol. 87, no. 13: 7655-7667. 14. Nolting,Jacqueline,M; Dennis,Patricia; Long,Lindsey; Holtvoigt,Lauren; Brown,Deniele; King,Mary,Jo; Shellbarger,Wynonna; Hanley,Chris; Killian,Mary,Lea; Slemons,Richard,D, "Low Pathogenic Influenza A Virus Activity at Avian Interfaces in Ohio Zoos, 2006-2009" (2013) Avian Diseases. Vol. 57, no. 3: 657-662. 15. Bowman,Andrew,S; Workman,Jeffrey,D; Nolting,Jacqueline,M; Nelson,Sarah,W; Slemons,Richard,D, "Exploration of risk factors contributing to the presence of influenza A virus in swine at agricultural fairs" (2014) Emerging Microbes & Infections. Vol. 3, e5. 2014. 16. Fries,Anthony,C; Nolting,Jacqueline,M; Bowman,Andrew,S; Killian,Mary,L; Wentworth,David,E; Slemons,Richard,D, "Genomic analyses detect Eurasian-lineage H10 and additional H14 influenza A viruses recovered from waterfowl in the Central United States" (2014) Influenza and Other Respiratory Viruses. Vol. 8, no. 4: 493- 498.

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17. Edwards,Jody,L; Nelson,Sarah,W; Workman,Jeffrey,D; Slemons,Richard,D; Szablewski,Christine,M; Nolting,Jacqueline,M; Bowman,Andrew,S, "Utility of snout wipe samples for influenza A virus surveillance in exhibition swine populations" (2014) Influenza and Other Respiratory Viruses. Vol. 8, no. 5: 574-579. 18. Bowman,Andrew,S; Nelson,Sarah,W; Page,Shannon,L; Nolting,Jacqueline,M; Killian,Mary,L; Sreevatsan,Srinand; Slemons,Richard,D, "Swine-to-Human Transmission of Influenza A(H3N2) Virus at Agricultural Fairs, Ohio, USA, 2012". (2014) Emerging Infectious Diseases. Vol. 20, no. 9: 1472-1480. 19. Fries AC, Nolting JM, Bowman AS, Lin X, Halpin RA, Wester E, Fedorova N, Stockwell TB, Das SR, Dugan VG, Wentworth DE, Gibbs HL, Slemons RD, "Spread and persistence of influenza a viruses in waterfowl hosts in the north american Mississippi migratory flyway" (2015) Journal of Virology. Vol. 89, no. 10: 5371- 5381. 20. Bowman AS, Nolting JM, Massengill R, Baker J, Workman JD, Slemons RD, "Influenza A Virus Surveillance in Waterfowl in Missouri, USA, 2005-2013" (2015) Avian Diseases. Vol. 59, no. 2: 303-308. 21. Bowman AS, Nolting JM, Nelson SW, Bliss N, Stull JW, Wang Q, Premanandan C, "Effects of disinfection on the molecular detection of porcine epidemic diarrhea virus" (2015) Veterinary Microbiology. Vol. 179, no. 3-4: 213-218. 22. Nolting JM, Szablewski CM, Edwards JL, Nelson SW, Bowman AS, "Nasal wipes for influenza A virus detection and isolation from swine" (2015) Journal of Visualized Experiments. Vol. 106, e53313. 23. Nelson MI, Wentworth DE, Das SR, Sreevatsan S, Killian ML, Nolting JM, Slemons RD, Bowman AS, "Evolutionary dynamics of influenza A viruses in US exhibition swine." (2016) Journal of Infectious Diseases. Vol. 213, no. 2: 73-182. 24. Krauss,Scott; Stallknecht,David,E; Slemons,Richard,D; Bowman,Andrew,S; Poulson,Rebecca,L; Nolting,Jacqueline,M; Knowles,James,P; Webster,Robert,G, "The enigma of the apparent disappearance of Eurasian highly pathogenic H5 clade 2.3.4.4 influenza A viruses in North American waterfowl" (2016) Proceedings of the National Academy of Sciences of the United States of America. Vol. 113, no. 32: 9033-9038. 25. Bliss,N; Nelson,S,W; Nolting,J,M; Bowman,A,S, "Prevalence of Influenza A Virus in Exhibition Swine during Arrival at Agricultural Fairs". Zoonoses and Public Health. Vol. 63, no. 6: 477-485. 2016. 26. Krauss,Scott; Stallknecht,David,E; Slemons,Richard,D; Bowman,Andrew,S; Poulson,Rebecca,L; Nolting,Jacqueline,M; Knowles,James,P; Webster,Robert,G, "Reply to Ramey et al.: Let time be the arbiter.". Proceedings of the National Academy of Sciences of the United States of America. Vol. 113, no. 43: E6553-E6554. 2016. ix

27. Nelson,Martha,I; Stucker,Karla,M; Schobel,Seth,A; Trovao,Nidia,S; Das,Suman,R; Dugan,Vivien,G; Nelson,Sarah,W; Sreevatsan,Srinand; Killian,Mary,L; Nolting,Jacqueline,M; Wentworth,David,E; Bowman,Andrew,S, "Introduction, Evolution, and Dissemination of Influenza A Viruses in Exhibition Swine in the United States during 2009 to 2013". Journal of Virology. Vol. 90, no. 23: 10963- 10971. 2016. 28. Lauterbach,Sarah,E; Zentkovich,Michele,M; Nelson,Sarah,W; Nolting,Jacqueline,M; Bowman,Andrew,S, "Environmental surfaces used in entry-day corralling likely contribute to the spread of influenza A virus in swine at agricultural fairs". Emerging Microbes & Infections. Vol. 6, e10. 2017. 29. Urig,Hannah,E; Nolting,Jacqueline,M; Mathys,Dimitria,A; Mathys,Blake,A; Bowman,Andrew,S, "Influenza A Virus Surveillance in Underrepresented Avian Species in Ohio, USA, in 2015". Journal of Wildlife Diseases. Vol. 53, no. 2: 402- 404. 2017. 30. Mathys,Dimitria,A; Mollenkopf,Dixie,F; Nolting,Jacqueline; Bowman,Andrew,S; Daniels,Joshua,B; Wittum,Thomas,E, "Extended-Spectrum Cephalosporin-Resistant Enterobacteriaceae in Enteric Microflora of Wild Ducks.". Journal of wildlife diseases. Vol. 53, no. 3: 690-694. 2017. 31. Martin,Brigitte,E; Bowman,Andrew,S; Li,Lei; Nolting,Jacqueline,M; Smith,David,R; Hanson,Larry,A; Wan,Xiu-Feng, "Detection of Antigenic Variants of Subtype H3 Swine Influenza A Viruses from Clinical Samples". Journal of Clinical Microbiology. Vol. 55, no. 4: 1037-1045. 2017. 32. Xu,Yifei; Ramey,Andrew,M; Bowman,Andrew,S; Deliberto,Thomas,J; Killian,Mary,L; Krauss,Scott; Nolting,Jacqueline,M; Torchetti,Mia,Kim; Reeves,Andrew,B; Webby,Richard,J; Stallknecht,David,E; Wan,Xiu-Feng, "Low- Pathogenic Influenza A Viruses in North American Diving Ducks Contribute to the Emergence of a Novel Highly Pathogenic Influenza A(H7N8) Virus". Journal of Virology. Vol. 91, no. 9: 1-13. 2017 33. Lorbach JN, Wang L, Nolting JM, Benjamin MG, Killian ML, Zhang Y, Bowman AS, "Porcine Hemagglutinating Encephalomyelitis Virus and Respiratory Disease in Exhibition Swine, Michigan, USA, 2015." Emerg Infect Dis. Vol. 23, no. 7: 1168. 2017. 34. Cha, W., Fratamico, P. M., Ruth, L. E., Bowman, A. S., Nolting, J. M., Manning, S. D., & Funk, J. A. (2018). Prevalence and characteristics of Shiga toxin-producing Escherichia coli in finishing pigs: Implications on public health. International journal of food microbiology, 264, 8-15.

35. Lauterbach, S. E.; Wright, C. M.; Zentkovich, M. M.; Nelson, S. W., Lorbach, J. N.; Bliss, N. T.; Nolting, J.N.; Pierson, R.M.; King, M. D.; Bowman, A. S. (2018). Detection of influenza A virus from agricultural fair environment: air and surfaces. Preventive Veterinary Medicine.

Fields of Study

Major Field: Agricultural and Extension Education

Table of Contents

Abstract ...... ii

Dedication ...... iv

Acknowledgments ...... v

Vita ...... vi

Positions and Employment ...... vi

Publications ...... vii

Fields of Study ...... xi

Table of Contents ...... xii

List of Tables...... xvii

List of Figures ...... xviii

Chapter 1: Introduction ...... 1

Background ...... 1

Purpose of Study ...... 5

Problem Statement ...... 6

Research Questions ...... 7

Definition of Terms ...... 7

Theoretical Framework ...... 9

Conceptual Framework ...... 11 xii

Limitations ...... 12

Basic Assumptions ...... 13

Chapter 2: Review of the Literature ...... 14

Introduction ...... 14

Influenza A Virus in Swine Populations ...... 14

Influenza A Viruses at the animal-human interface ...... 17

Influenza A Viruses in Human ...... 21

Educational Programs ...... 22

Learning Theories and Theoretical Framework ...... 25

Agricultural Education ...... 28

Summary ...... 30

Chapter 3: Educating youth swine exhibitors on influenza A virus transmission at agricultural fairs ...... 32

Summary ...... 32

Background ...... 33

Methods and Materials ...... 36

Curriculum Development ...... 37

Instrumentation ...... 38

Validity and reliability of Instrumentation ...... 38

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Study Sample ...... 39

Data Analysis ...... 39

Results ...... 40

Discussion...... 42

Chapter 4: Swine Zoonotic Disease Risks and Prevention ...... 45

Summary ...... 45

Background ...... 46

Methods and Materials ...... 47

Instrumentation ...... 47

Study Sample ...... 48

Data Analysis ...... 48

Results ...... 50

Dissemination of Chapter ...... 50

Skill-a-thon ...... 50

Discussion...... 51

Chapter 5: Becoming a Swientist ...... 54

Summary ...... 54

Background ...... 55

Methods and Materials ...... 55

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Training Events ...... 55

Study Sample ...... 58

Data Analysis ...... 58

Results ...... 59

Hog Wild at Hartford ...... 59

World Pork Expo ...... 60

Healthy Habits Selfies ...... 64

Discussion...... 67

Chapter 6: Can recommendations for reducing zoonotic transmission of influenza A viruses from swine impact human attitudes and behaviors? ...... 71

Summary ...... 71

Background ...... 72

Methods and Materials ...... 73

Instrumentation ...... 73

Validity of Instrument ...... 73

Study Sample ...... 74

Data Analysis ...... 75

Results ...... 75

Discussion...... 78

Chapter 7: Recommendations, Future Research, and Conclusions ...... 81

Recommendations ...... 81

Future Research ...... 81

Conclusions ...... 83

References ...... 87

Appendix A: Pre and Post-test ...... 92

Appendix B: Swine Zoonotic Disease Risks and Prevention chapter ...... 97

Appendix C: Minimizing influenza in show pigs survey ...... 104

Appendix D: Scenario Based Training Lesson Plan ...... 107

Appendix E: Swientist logo ...... 111

Appendix F: Measures to Minimize Influenza Transmission at Swine Exhibitions ...... 113

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List of Tables

Table 1. Knowledge scores at pre- and post-test assessments ...... 41

Table 2. Regression table accounting for variance in post-test scores ...... 42

Table 3. Descriptive statistics for each swine skill-a-thon station from the 2017 Ohio

State Fair...... 51

Table 4. Frequency of heathy habit categories submitted via selfies ...... 65

Table 5. Number of survey respondents representing each state included in the study. .. 76

Table 6. Summary of swine jackpot exhibitor perceptions and opinions of the recommendations put forth in the Measures to Minimize Influenza Transmission at Swine

Exhibitions document...... 77

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List of Figures

Figure 1. Engerstrom‟s activity system ...... 10

Figure 2. Conceptual framework ...... 11

Figure 3. Photos from "Becoming a Swientist" at World Pork Expo ...... 61

Figure 4. A subset of photos and captions of healthy habits submitted by “Becoming a

Swientist” participants...... 65

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Chapter 1: Introduction

Background

Influenza A is a zoonotic disease threatening economies and public health worldwide. In the United States, seasonal strains of influenza A virus commonly cause epidemics of acute respiratory disease resulting in an estimated 200,000 hospitalizations and 36,000 deaths annually (Smith et al., 2006). Novel strains of influenza A virus with pandemic potential pose a disastrous risk to public health that could result in millions of lives lost and tumultuous economic futures. Interspecies transmission of influenza A viruses (IAVs) is believed to be a principal mechanism contributing to emergence of novel influenza A viruses that threaten public health (Reid & Taubenberger, 2003;

Webster, 2002).

Type A influenza viruses have negative-sense, single-stranded, segmented RNA genomes permitting antigenic drift and antigenic shift to occur. Unlike the gradual antigenic drift, a major antigenic shift resulting from genomic reassortment allows for the emergence of a novel IAV strain. Influenza A viruses can infect a wide range of hosts including humans, pigs, horses, dogs, sea mammals, and many avian species. Although wild birds are the natural reservoirs of all IAVs, pigs are known as „mixing vessels‟ of

IAVs because they have receptors in their respiratory tract for swine-, human-, and avian- origin influenza A viruses (Ma, Kahn, & Richt, 2008). A novel IAV strain can be generated if a pig is infected with two different influenza A viruses simultaneously (Ito et al., 1998). These genetically reassortant viruses could potentially be maintained in the swine population and/or transmitted to another host species making swine a source for 1

influenza A viruses infecting humans (Webby, Rossow, Erickson, Sims, & Webster,

2004).

Zoonotic transmission of influenza A viruses between pigs and people has been reported periodically worldwide (Myers, Olsen, & Gray, 2007) and has received considerable publicity following the H3N2 variant influenza A virus (H3N2v) outbreaks of 2011-2016. Zoonotic transmission of influenza A viruses requires close contact between animals and humans as occurs at the swine-human interface. In the United

States, approximately 150 million people attend agricultural fairs each year (International

Association of Fairs & Expositions, 2015) allowing for more swine-human interactions than any other swine-animal interface in the world. Individuals who would not otherwise have contact with pigs or their pathogens have direct contact with both at agricultural fairs and exhibitions.

Agricultural fairs and exhibitions bring together pigs from multiple locations with various backgrounds, and allow them to be concentrated and comingled for an extended period of time (3-10 days). Some of these pigs likely have attended multiple exhibitions and may be shedding a variety of viruses at the time of show. A single pig becoming co- infected with multiple viral strains can result in a novel reassortant IAV. Increased potential for zoonotic disease transmission occurs when immunologically naïve people are exposed to pigs at the unique swine-human interface created by fairs. (Bowman,

2012). During 2012, 306 cases of H3N2v were documented (Jhung et al., 2013) with thousands more believed to have gone unreported (Biggerstaff et al., 2013). Most of the people who became infected with H3N2v had significant swine exposure occurring at

agricultural fairs and livestock exhibitions. Data from the H3N2v outbreaks show children have the highest risk of infection with H3N2v (Epperson et al., 2013), which is particularly concerning because the vast majority of pigs are exhibited as part of youth agricultural education programs (4-H and FFA). While human-to-human transmission of

H3N2v has been limited to date, people infected at fairs may serve as a pathway to disseminate swine-origin influenza A viruses in their local community (Saenz, Hethcote,

& Gray, 2006). Children exposed to their infected pigs may not develop clinical illness, however they could serve as a carrier to other naïve youth at school, church, and other community activities.

The swine-human interface at fairs also promotes human-to-swine transmission of influenza A virus. Human-to-swine transmission is credited as a primary source of the genetic diversity seen in current swine-lineage influenza A viruses (Karasin, Carman, &

Olsen, 2006; Olsen, 2002; Vincent et al., 2009). As was seen after the emergence of the

2009 H1N1 pandemic virus, human-to-swine transmission of influenza A virus can be economically devastating for the pork industry because of decreased domestic sales, restrictions imposed by export partners, and production losses due to disease.

Unfortunately, there is little scientific evidence upon which to base changes in policies and management practices to reduce the risk of the zoonotic transmission of influenza A viruses between pigs and people at fairs.

Ohio is unique in the ability to study these issues because an active IAV surveillance program was established in Ohio during 2009 to monitor the pigs at fairs.

The results of this ongoing project show approximately 25% of Ohio fairs have pigs

shedding IAV by the conclusion of the fair (Bowman et al, 2012). Within those fairs where there are pigs shedding IAV, the estimated prevalence of IAV infection in the swine population is >66%, indicating the viral burden in these settings is high. Further complicating the identification and removal of infected animals is the fact that majority of IAV infections among swine at the fairs are subclinical. Agricultural exhibitions are imperative to attracting the interest of and training the next generation of agriculturalist, with whom we rely upon for safe and secure food sources.

Exhibition swine are frequently shown at agricultural fairs but may also be shown multiple times across locations in exhibitions that are open to any age competitor (also known as „jackpot shows‟). Preliminary data collected collaboratively by The Ohio State

University and the Ohio Pork Council suggests up to 47% of swine shown at jackpot events are shedding IAVs at the time of the show. We hypothesize that IAV is being amplified at jackpot shows and then introduced to fairs via these exhibition swine.

Therefore, decreasing IAV transmission during jackpot shows would likely reduce the

IAV prevalence at downstream agricultural fairs, making control of IAV during the jackpot show season key to protecting public health.

To increase awareness among youth swine exhibitors regarding the risks associated with IAV infected swine, scenario-based training exercises were developed and implemented in 2015. Additionally, social media platforms were used to disseminate information to youth across a larger geographical area and curriculum describing zoonotic diseases and their risks was developed for the swine resource handbook.

Although these activities have been shown to be successful in disseminating information

by measuring significant gains in knowledge, they only target youth involved in youth organization such as 4-H and FFA. Many of the youth involved in showing pigs at jackpot shows are not involved in these agricultural organizations because these shows are independent swine exhibitions open to all swine producers to advertise the quality of animals they produce and do not have stringent age limits for showmen. The development and implementation of hands-on learning activities based on constructivist learning theories was used to increase awareness of the animal and human health risks associated with IAVs circulating in the exhibition swine for these jackpot showmen. This project expanded previous efforts to encompass not only all of Ohio, but the national show circuit participants to increase impact.

Purpose of Study

Due to the ecology of IAVs and their predilection to mutate, each transmission across the animal-human species barrier could result in the next pandemic influenza A virus strain. Influenza A virus pandemics have historically had catastrophic consequences on human health and economics, therefore any mitigation that can be done to minimize the threat of an emergent virus can potentially save countless animal and human lives.

Agricultural exhibitions are imperative to attracting the interest of and training the next generation of agriculturalist, with whom we rely upon for safe and secure food sources. However, contracting influenza A virus from swine at agricultural exhibitions is not only detrimental to the health of these children, but could also deter them from pursuing a career in agriculture. Understanding exhibitors‟ perception of the recommendations and barriers to adoption is critical because exhibitor compliance with

proposed mitigation strategies is key to decreasing IAV burden in swine, thus reducing the risk of IAV transmission from pigs to people.

Problem Statement

Educating youth regarding the risk of zoonotic disease is an important animal and public health concern as nearly three out five new human illnesses are zoonotic. (CDC, 2017)

Justification for increased diligence in this area is highlighted by the continual cases of

H3N2v reported in youth swine exhibitors associated with agricultural fairs (Schicker et al.,

2016). Animal and public health experts must work alongside extension educators to create and implement programming that is effective and engaging. Building a repertoire of mitigation strategies based on scientific evidence is a key component to the development of sustainable educational programming. Leading transitions is impossible without evidence to support the proposed behavioral changes, therefore data collected from the studies conducted by the Animal Influenza Ecology and Epidemiology Research Program has been used to develop a multi-faceted educational program to educate youth on the risk associated with zoonotic disease.

Many youth involved in swine exhibition are unaware of the risk posed by influenza A viruses, and other zoonotic diseases, that are transmitted between swine and humans. As a result, management practices to prevent transmission events are not being followed and each year humans become infected with influenza A viruses from exposure to exhibition swine. Educating youth about the risks associated and potential mitigation strategies to lessen those risks is being initiated to protect human and animal health. As a result the following research questions were developed. 6

Research Questions

1) How do youth swine exhibitors‟ knowledge about IAVs change when

participating in scenario-based training exercises?

2) What predictor variables determine IAV knowledge through scenario-based

training exercises?

3) Has the dissemination of the “Swine Zoonotic Disease Risks and Prevention”

chapter of the Swine Resource Handbook been effective?

4) How did the “Becoming a Swientist” Program influence the healthy habits of

swine exhibitors?

5) What were the perceptions and behaviors of jackpot swine exhibitors related to

IAV?

Definition of Terms

The major terms of this study were operationally defined as follows:

4-H: of or relating to a program set up the U.S. Department of Agriculture originally in rural areas to help young people become productive citizens by instructing them in useful skills (as in agriculture, animal husbandry, and carpentry), community service, and personal development (4-H. (n.d.). Retrieved November 20, 2017, from https://www.merriam-webster.com/dictionary/4-H)

Activity theory: Activity theory is a conceptual framework originating from the sociocultural tradition in Russian psychology. The foundational concept of the framework is

“activity”, which is understood as purposeful, transformative, and developing interaction between actors (“subjects”) and the world (“objects”). The framework was originally developed by the Russian psychologist Aleksei Leontiev (Leontiev, 1978; Leontiev,

1981)

FFA: FFA is an intracurricular student organization for those interested in agriculture and leadership. It is one of the three components of agricultural education. (What is FFA?

Retrieved November 20, 2017, from https://www.ffa.org/about/what-is-ffa)

Influenza A virus (IAV): moderate to severe influenza that in humans is marked especially by sudden onset, fever, sore throat, fatigue, muscle aches, inflammation of the respiratory mucous membranes, and couch, that has numerous variants caused by subtypes (such as H1N1, H2N2, H3N2) of an orthomyxovirus (species Influenza A virus) infecting humans and various animals (such as birds or pigs), and that may occur in seasonal epidemics or sometimes pandemics following mutation in the causative virus

(Influenza. (n.d.). Retrieved November 20, 2017, from https://www.merriam- webster.com/dictionary/influenza)

Jackpot swine exhibitors: Youth, ages 3-21, who participate in independent swine exhibitions at local, state, or national levels to earn prize money and to advertise swine genetics. 8

Scenario-based training: uses interactive scenarios to support active learning strategies such as problem-based or case-based learning. It normally involves students working their way through a storyline, usually based around an ill-structured or complex problem, which they are required to solve. In the process students must apply their subject knowledge, and critical thinking and problem solving skills in a safe, real-world context.

(Clark, R., 2009)

Youth swine exhibitors: Youth, ages 8-19, who participate in youth agricultural organizations, such as 4-H and FFA, to complete swine production projects and exhibit swine at agricultural exhibitions.

Zoonosis: an infection or disease that is transmissible from animals to humans under natural conditions; also; an infection or disease that is transmissible between animals and humans (Zoonosis. (n.d.). Retrieved November 20, 2017, from https://www.merriam- webster.com/dictionary/zoonosis)

Theoretical Framework

The theory that guided this study was the Activity Theory as it relates to the development of constructivist learning environments (CLE). “Activity theory is a powerful soci- cultural and socio-historical lens through which we can analyze most forms of human activity” (Jonassen, 1999, p 62). Activity theory is not a methodology, but is a framework for studying varied forms of cognitive development at both the

individual and social levels (Leont‟ev, 1972). When examining human activity the environment in which they are in, the type of activities they are engaging in, the goals and intentions of participants, the rules pertaining to the activity, and the objectives or results produced by the activity must all be accounted for (Jonassen, 1999).

In 1987, Engerstrom developed a triangular model for organizing activities into activity systems. See Figure 1. An activity production includes a subject, an object, tools, and the actions that affect an outcome (Nardi, 1996). Activity has a bi-direction relationship with actions which are chains of operations. Initially all operations are activities because an individual consciously choses to perform the operation, however over time the operation becomes more automatic. In the case of this study, researchers are specifically concerned with developing materials considered to be tools in Engerstroms conceptual framework.

Figure 1. Engerstrom‟s activity system

Conceptual Framework

Engerstrom‟s activity system is the basis of the conceptual framework for this study. Jonassen defined the „tool‟ as anything used in the transformation process which shapes the way people think and act. In this study the tool will be scenario-based training models, the resource handbook chapter, and the “Becoming a Swientist” program, all used to teach swine youth exhibitors about the risks associated with influenza A viruses and the mitigation strategies used to prevent disease transmission. The object in the framework is altered management practices, which will be evaluated through survey. In addition, following the administration of the tool, researchers will investigate outcomes by measuring the estimated prevalence of influenza A viruses in swine compared to previous years. Although this training tool is not the only variable that affects prevalence, it can provide insight into the efficacy of the deployed tools.

Exhibition swine have zoonotic diseases that are transmitted to people

Mitigation strategies Tool Object Outcome Altered can reduce disease Developed Reduced IAV transmission management training materials practices prevalance  72 hour rule

 Weigh-in strategies

 Environmental contamination Figure 2. Conceptual framework

Limitations

Several limitations exist due to the voluntary nature of this study. Limitations for each individual research question are as follows:

Research Question 1-2: Establishing a gain in knowledge as a result of scenario- based training exercises was reliant upon voluntary participation in the training activities.

Those whom participated in the training activities may have been beginner exhibitors who were attempting to gain as much knowledge as possible, which may have lowered pre-test scores, inflating the difference between pre and post-test means. In addition, not all training exercise participants completed the pre- and post-test instrumentation, decreasing the overall sample size from which to draw conclusions.

Research Question 3: The effectiveness of the dissemination of the “Swine

Zoonotic Disease Risks and Prevention” chapter of the Swine Resource Handbook was measured through skill-a-thon scores of a small cohort of exhibitors who participated in a tie-breaker event at the Ohio State Fair (OSF) swine skill-a-thon. Youth who exhibit pigs at the OSF may be more active showman who would have a deeper understanding of swine husbandry based on their experience. Knowledge regarding zoonotic diseases possessed by youth may or may not have been gained though the handbook chapter.

Research Question 4: The influence the “Becoming a Swientist” Program had on swine exhibitor‟s behavior was self-reported through the uploading of selfies on a secure webpage. Youth who did not choose to upload photos may or may not have adopted suggested healthy habits.

Research Question 5: The survey to measure the perceptions and behaviors of jackpot swine exhibitors related to IAV was voluntary and therefore may not represent the opinions of all jackpot swine exhibitors. In addition, the instrumentation used to measure perceptions and behaviors may not be easily interpreted by participants, and therefore not accurately portray their true thoughts and feelings.

Basic Assumptions

The investigators made the following assumptions regarding the study:

1. Participants responding to surveys fully understand what is being asked by the

instrument questions and respond based on their true beliefs and actions.

2. Swine exhibitors participating in study activities had similar levels of existing

knowledge before participating in educational programming.

3. Jackpot swine exhibitors continued to practice recommended healthy habits after

taking a picture to submit online.

4. Jackpot swine exhibitors were previously familiar with recommendations outlined

in the “Measures to Minimize Influenza Transmission at Swine Exhibitions”

document.

Chapter 2: Review of the Literature

Introduction

This chapter begins with an overview of influenza A viruses in swine populations, as this is the underlying justification for conducting this study. Next, literature relating to influenza A viruses at the animal –human interface will be discussed, followed by information regarding influenza A viruses in humans. Next, topics shift to include information from literature on educational programming, learning theories, the theoretical theory used in this study, and agricultural education. The chapter concludes with a summary of the literature review.

Influenza A Virus in Swine Populations

Influenza A virus causes respiratory illness in humans and mammals, resulting in tremendous detrimental health and economic impacts. Understanding the ecology of the disease in the animal reservoir is imperative to developing mitigation strategies to protect public health; which is the overarching goal of this educational program. In 2002,

Webster reviewed available literature in the areas of natural reservoirs for influenza A viruses (IAV), the evolutionary pathways for IAV, IAV genetic information, IAV in pigs,

H5N1 highly pathogenic IAV, and IAV live bird markets to formulate challenges for virologist in the 21st century. The identified challenge to devise an international surveillance system using accumulated epidemiological data is not a simple task, as

influenza viruses infect a variety of hosts and are undergoing continuous mutation

(Webster, 2002).

Swine play an important role in the ecology of IAVs contributing to overall viral genomics, which impacts human health. In 2008, Ma et al. reviewed the available peer reviewed literature to investigate the role pigs play as a mixing vessel for influenza viruses. (Ma et al., 2008) Because swine are susceptible to infection with both avian and human influenza viruses, novel reassortant influenza viruses can be generated in this mammalian species by reassortment of influenza viral segments leading to the “mixing vessel” theory. Genetic reassortment among avian, human and/or swine influenza virus gene segments has occurred in pigs and some novel reassortant swine viruses have been transmitted to humans. Examples show that pigs could transmit novel viruses from an avian reservoir to other mammalian species.

A literature review by Capua and Munoz was completed in 2013 to better understand how influenza A viruses cross the species barrier; the role receptor sites play; host cell biology; viral exit of the cell; and the role of the animal reservoir. They conclude that only some of the mechanisms behind inter species transmissions have been identified and that further work needs to be done to better understand all the mechanisms involved. The key questions identified to be addressed in the future include whether a single unique pathway is used by viruses to cross the species barrier or if there are multiple pathways leading to successful emergence and stability of novel IAV strains.

They stress that it is important for influenza researchers to standardize definitions,

priorities, and methods to develop clear objectives for a framework of coordinated research (Capua & Alexander, 2008).

Another research team, Peiris et al, described the need for continued surveillance for influenza A viruses in animal populations. They examined the number of genomic sequences that ware being deposited in public databases and concluded that understanding the viral and host determinates that permit animal influenza to transmit between humans is one of the most important research questions of today. Even though pandemic precursors may not have been identified at the time of isolation, prioritizing influenza A virus isolates from vaccine preparation is critical, as it is difficult to predict which virus will cause the next human pandemic and when the pandemic might begin

(Peiris, Poon, & Guan, 2012). Importantly, the establishment and spread of reassortant mammalian-adapted viruses from pigs to humans could happen anywhere in the world.

Therefore, both human and veterinary research needs to give more attention to potential cross-species transmission capacity of influenza A viruses.

One characteristic of IAVs that complicate mitigation is the diversity of genomes within host species. In 2013, Ye et al. described the serological two distinct antigenic clusters were previously identified among the H3N2 swine influenza A viruses (IAVs) and were designated H3N2SIV-alpha and H3N2SIV-beta A consistent mutation was observed at position 189 of hemagglutinin (R189K) between H3N2 SIV-alpha and

H3N2SIV-beta fair isolates. To evaluate the contribution of R189K mutation to the antigenic drift from H3N2SIV-alpha to H3N2SIV-beta, four reassortant viruses with

189R or 189K were generated. The antigenic cartography demonstrated that the R189K

mutation in the hemagglutinin of H3N2 IAV contributed to the antigenic drift, separating these viruses into H3N2SIV-alpha to H3N2SIV- beta. This R189K mutation was also found to contribute to the cross-reaction with several ferret sera raised against historical human IAVs with hemagglutinin carrying 189K. This study suggests that the R189K mutation plays a vital role in the antigenicity of swine and human H3N2 IAVs and identification of this antigenic determinant will help rapidly identify antigenic variants in influenza surveillance. In vitro studies with porcine cells and influenza virus and on the immune responses of pigs against human, avian, and swine influenza viruses in vivo were performed to investigate the utility of using swine as animal models for human disease.

The acceptance of pigs as a suitable and valuable model to assess porcine immune response could have great impacts on immunology, allowing porcine to become the “gold standard‟ large animal model in immunology (Crisci, 2013).

Influenza A Viruses at the animal-human interface

Advances in the commercial swine industry in the US have greatly reduced the number of human interactions with swine, reducing the risk of animal-human disease transmission. However, agricultural exhibition provide a unique setting in which hundreds of thousands of people potentially come into contact with pigs each year in the

US. This animal-human interface provides an opportunity for swine-origin IAVs to jump the species barrier and infect humans. In 2015, Nelson and Vincent reviewed swine and human influenza A virus surveillance data along with full length genomic sequences to better understand the ecology and evolution of zoonotic IAVs. The recent increase in 17

IAV surveillance in pigs has revealed that influenza transmission from humans to swine is occurring more frequently than transmission from swine to humans and is globally seeding swine with genetically diverse virus strains. Documented transmission of pathogens from humans to swine has never occurred in this scale for other pathogens.

Bias toward pigs to people transmission needs to be addressed to better understand the bidirectional nature of the human-swine interface and the threats posed by that interaction.

In order to better understand the ecology of IAVs at the animal-human interface it is important to understand how viruses spread between pigs and environmental factors that play a role in transmission. In 2013, Corzo et al. collected air samples from swine barns housing pigs infected with influenza A virus (IAV) as well as external to exhaust fans, and downwind from farms up to 2.1 km away. Cyclonic air samplers were used to circulate air through viral transport media. Samples were tested in the laboratory for

IAVs using real time reverse transcriptase PCR, which identified IAV in the air surrounding three of the four farms tested. Viruses with subtypes of H1N1, H1N2, and

H3N2 were all identified within the air samples collected through this effort. This study provides evidence for the risk or aerosol transmission of IAVs in areas surrounding infected pigs.

Commercial swine, as were used in the air sampling study are not the only swine populations that play a role in IAV ecology. Bowman et al. (2012) compared influenza A viruses (IAVs) isolated from pigs at a county fair associated with six human cases of

H3N2v. Virus isolation attempts were performed on 34 swine nasal swabs collected from pigs being exhibited at an Ohio county fair. Full length genomic sequencing was

completed using the Ion Torrent platform to establish consensus sequences for all eight genomic segments, in conjunction with the Ohio Department of Health and Center of

Disease Control (whom isolated and sequenced the human isolates). Phylogenetic analysis was performed using the Maximum Parsimony or Maximum Likelihood methods. Analysis showed >99% nucleotide similarity between the swine and human origin IAVs indicating the human infections were caused by exposure to infected pigs at the individual county fair.

In order to develop mitigation strategies to reduce the risk of bi-directional transmission of IAVs at county fairs, Bowman et al. (2014) examined risk factors that contribute to swine being infected with IAVs while being exhibited at agricultural fairs.

Data from surveillance efforts conducted in 2012 along with site surveys were used to identify risk factors that could be used to predict the likelihood of an individual fair having pigs shedding IAVs. Fisher exact test was used to assess differences in proportion and the Kruskal-Wallis equality-of-populations rant test was used for continuous variables. Of the 40 tested fairs, 10 had pigs shedding IAVs. Analysis of the data showed that the adjusted odds of having IAV infected pigs at a fair were 1.27 higher for every 20 pig increase in the size of the swine show. Also, four of the five fairs that hosted breeding shows in addition to market swine shows had pigs that tested positive for IAV.

Understanding the risk of swine exhibitors becoming infected was accomplished when

Skowronski et al (2013), estimated potential epidemic attack rates (AR) based on age- specific estimates of sero-suceptibility and social interactions in regards to variant cases

H3N2 swine-origin influenza A viruses. The study was completed using typical influenza

characteristics, basic reproduction number, and effective contacts taking into account age-specific sero-protection rates. Simulated AR for the novel swine-origin H3N2v was

6% highest in children 6-11 years. The findings of these studies can be used by public health officials when determining appropriate mitigation strategies to minimize the risk of IAVs being transmitted between pigs and people at agricultural fairs.

Continual surveillance of IAV in exhibition swine is needed to evaluate the effectiveness of mitigation strategies. In 2012, Bowman et al. conducted active surveillance for influenza A viruses circulating in exhibition swine at county fairs because fairs have been shown to be an opportunity for bidirectional transmission of

IAVs between pigs and people. Nasal swabs were collected from pigs at 40 Ohio agricultural fairs, and seven of those fairs were linked with human cases of H3N2v. The nucleotide identities were >99.5% identical between IAV isolates from pigs and from humans indicating that this virus strain was widely circulating among exhibition swine in

2012.

Conducting surveillance using the most effective techniques is vital in establishing sustainable research endeavors. In 2013, Bowman et al published research studying the effectiveness of two virus isolation methods for detecting influenza A virus from nasal swabs collected from pigs exhibited at county fairs. The methods compared were virus isolation in madine-darby canine kidney cell (MDCK) culture and in embryonating egg culture (ECE). During 2009, nasal swabs were collected from 221 clinically healthy pigs and were tested with both methods. Of these samples, 40 (18.1%) were positive for IAV in MDCK culture and 13 (5.9%) were positive in ECE. The

effectiveness and cost savings of MDCK cell culture justify the use of this technique in future surveillance efforts.

Influenza A Viruses in Human

Influenza A virus infections in humans is of great public health concern, especially when the time to most common ancestor in an animal reservoir is contemporary. In 2015 Kramer reviews zoonotic influenza viruses with pandemic potential and describes technologies that are leading to universal vaccines. He describes that influenza A viruses are responsible for approximately 500,000 deaths each year and prophylactic vaccination is the best tool to prevent disease in the human population.

Although many factors contribute to the inefficacy of contemporary flu vaccines; much research is ongoing to create a universal vaccination that could provide protection to any strain. Technologies such as novel adjuvants, reverse genetics, gene synthesis, recombinant vaccines, quadrivalent vaccines, and heterologous prime-boost regimens are among the candidates for improving current vaccines.

Understanding antibody response in humans is of utmost importance when developing a universal influenza vaccine. In 2015, Hoa et al. published work done in

Vietnam pertaining to the antibody response in adults and children to a H3N2 reassortant virus that was circulating in swine in 2010. The virus had surface proteins (HA and NA) from a human virus that had circulated in the population form 2004-2006 and internal gene segments from the commonly identified TRIG cassette. A total of 943 patients were enrolled with 495 from urban areas and 448 from rural areas. About 40% of the 21

participants were <20 years of age with the mean age of 33 and the range 2-91. Sera was tested using hemagglutination inhibition assay for a seasonal human virus

(A/Perth/16/2009) and a swine-origin virus (A/swine/BinhDuong/03-9/2010). The seroprevalence to the human H3N2 was 62.6% whereas the seroprevalence to the swine- origin virus was 54.6%, with no significant differences between urban and rural participants. Children <5 lacked antibodies to the swine-origin viruses, indicating the vulnerability of children to the reassortant virus.

In 2015, Miranda-Novales et al. described the serological response to the 2009 pandemic influenza A virus in pediatric patients with influenza-like illness, their household contacts, and exposed health care workers. A total of thirty pre-epidemic and

129 epidemic samples were collected and serum antibodies were measured against a

(H1N1)2009 pandemic virus along with two additional non-pandemic swine viruses using hemagglutination inhibition assay. Ninety-one percent of the pediatric patients,

63% of household contacts, and 41% of the healthcare workers had geometric mean titers

> 10 to the pandemic virus. Of the 32 patients confirmed to be infected with pandemic influenza A virus, 60% had antibody tiers for the pandemic strain, 53% had titers to an

H1N1 swine-origin virus, and 43% had titers to a H3N2 swine-origin virus. This evidence shows that previous exposure to swine-origin influenza A viruses provided no protection to the 2009 pandemic virus.

Educational Programs

One important way to prevent disease transmission is by educating individuals about disease transmission prevention and ways to keep them healthy. Several studies 22

have been conducted to study the effectiveness of such training activities. In 2015, Ghisi et al. conducted research on 306 patients enrolled in cardiac rehabilitation (CR) in

Toronto, Canada. The effect of the health action process approach (HAPA) theory based education program in cardiac rehabilitation was compared to traditional education on patient knowledge. The second objective was to investigate the theoretical correlates of exercise behavior among CR patients receiving theory-based education. CR patients were exposed to an existing or HAPA based six month educational curriculum in this quasi- experimental study. Surveys assessing exercise behavior, HAPA constructs, and pre- and post tests were used to assess effects. Of the 306 enrolled patients, 146 were exposed to

HAPA theory based curriculum and assessments were compared using descriptive statistics, mean scores, regression model, and path analysis. The HAPA theory based curriculum was found to have no significant impact on patient‟s knowledge or exercise behavior as predicted by the authors.

Another example of health care training was described by Washington et al.

(2014) who reported research conducted trauma training courses (TCC) with health care workers (HW) in Myanmar. Due to the lack of health care providers within conflict areas health care workers are supported and trained by community-based organizations and foreign non-governmental agencies. Training modules in the areas of breathing models, chest model, cricothyroidotmy model, circulation model, wound repair model, fracture/dislocation model, splintering, fasciotomy/amputation model, animal model, and other teaching aids were developed and implemented by researchers to comprise the

TCC. A total of 26 HW completed the post training evaluation after experiencing the

TCC; with 75% reporting they felt confident in applying what they learned. The HW that completed the TCC have treated 1,232 trauma patients with a 94% survival rate. Training course directors have found that the simulation models increase the understanding of clinical skills of the HWs beyond what is achieved solely with a lecture based format.

In 2015, Reeves et al. designed a competency based one day education course for dietitians on the diagnosis and management of cow‟s milk protein allergy in infants and children. Thirty-seven dietitians attended the one day training course and 32 participants completed assessments before the course, on the day of the course, and one month after the training to measure the effectiveness of the program. Statistical analysis was conducted using Wilcoxon signed rank test, McNemar test, Fishers exact test, and Chi- square to determine there was a significant increase in knowledge. Researchers conclude that educating dietitians using one day of teaching with pre and post-tests improved knowledge and competencies in the diagnosis and management of cow‟s milk protein allergy.

Health care workers are not the only group who gain information through educational training programs. In 2014, Perkins et al conducted a study to assess knowledge, perceptions, and attitudes towards evidence-based and other programs by identifying 225 Family and Consumer Science (FCS) or 4-H youth development educators whom completed a survey in 2009 from Hamilton et al. The educators were across 30 states and 96 percent were full time employees. Eight measures including: focus on prevention, support for prevention, obstacles to prevention programming, individual knowledge of evidenced-based programs (EBP), requirements and appeal of

EBP, extension commitment to EPBs, resources and support for collaboration and partnership, and collaboration and partnership activity were used to evaluate participant attitudes toward evidence-based programming, prevention programming, and collaboration activities. Multi-level mixed models including the least square means, the

95% confidence levels and significant values were used to analyze the data. Attitudes and knowledge base of EPBs were significantly higher for FCS educators than for 4-H educators.

Not only are educational programs for adults evaluated using scientific methods, but also those programs promoting healthy behaviors to children. In 2004, Murphey et al enrolled 30,916 Vermont students in grades 8-12 to answer six asset questions to predict risk and health promoting behaviors. The assets were related to the student‟s grades in school, their communications with parents about school, students perceptions of their role in school decision-making, students participation in after-school activities and volunteering, and students perception that they matter in their community. Chi square techniques and logistic regression was used to evaluate the data. The number of assets a student possessed was negatively related to students‟ engagement in each of seven risk behaviors. Academic success was the asset that contributed most to the outcome measure.

Authors concluded that students‟ assets contribute to the wellness of students.

Learning Theories and Theoretical Framework

When developing educational programming, it is important to take into account various learning theories from which to base curriculum. In 1999, Jonassen and Roher- 25

Murphy conducted research on the role of activity theory in designing constructivist learning environments (CLEs). Activity theory is a socio-cultural, soci-historical viewpoint that cans aide CLE developers in understanding human activity systems.

Conscious learning is described as emerging from activity, therefore CLE should be designed in a manner that activity is included to complete the hierarchy of operations; activity, action, and operation. Applying the activity theory can and should be employed when analyzing real-world situations for inclusion in CLEs, and thus the basis for the theoretical framework for the study described herein.

Youth educational programs, such as 4-H and FFA, rely on the constructivist learning environments to help youth develop life skills. In 1992, Boyd et al. conducted a survey to determine if youth involved in 4-H reported being more confident in their life skills than their non 4-H peers. A total of 309 4-H members and 558 non-4-H members in

Texas completed the survey which consisted of 21 life skill statements that were adapted from the Leadership and Development Inventory developed by Iowa State University. 4-

H members also completed questions regarding their level of participation in 4-H which included none, club, county, district, state, and national. The 4-H members reported significantly higher score for all life skill categories (working with groups, understanding self, communicating, making decisions, and leadership). In the second portion of the survey, 4-H members that reported being more involved in 4-H activities reported having higher perceived development of leadership life skills. This study indicates that 4-H programming in Texas is achieving its goal of preparing youth for adulthood.

In 2006, Roberts reviewed many articles in the agriculture education and extension literature to philosophically examine the experiential learning model. The key components in the process of experiential learning are that it is cyclical in nature and requires learners to experience distinct phenomenon which enhance the learning process.

The context in which learning occurs is divided into four dimensions; the level, duration, intended outcome, and the setting. Roberts, describes the theory in a three step process including experience, reflection, and generalization, whereas the cycle begins with an initial focus. Regardless of the version of the theory which is examined the key components remain relatively equal. Learners first experience a phenomenon, by completing or preforming an activity. Next they reflect upon the experience by sharing their observations publicly and processing the experience they just had. In the application step, learners generalize the information by connecting the learning experience to real- word examples and then apply the knowledge by using what they learned in a different yet similar situation. The application could occur in a real world setting or by completing an experiment in a classroom.

Understanding these theories is not enough to make an individual an effective agricultural educator. One must not only understand the theories, but have the knowledge to apply the theory in the classroom, and then evaluate the effectiveness. In 2007, Cole describes her experience working as an environmental educator in a rural high school in an area of New Mexico where there was a history of ethnic and cultural issues that continue to impact the lives of the residents. Although the teacher used many experiential techniques to teach her students about weather patterns, migration patterns, local native

fish reintroductions, and managements of local lands; the course never addressed the cultural issues of poverty, inequality, unequal access, school failures, and racial tensions.

In this philosophical article Cole examines fields such as environmental justice and critical pedagogy critique, support, and the advances the role of sociocultural issues and studies have had in environmental education. She urges other environmental educators to

“reconsider and reconstruct” the curriculum they use to enlighten their students.

Agricultural Education

Agricultural education (ag. ed.) programs are ideal venues to increase knowledge in the area of zoonotic diseases, as individuals involved have increased exposure to animal reservoirs. In addition, youth involved in ag ed programs are likely the future of agriculture and therefore critical leaders in preventing zoonotic diseases in the future. In

1993, Russell reported four objectives for College of Agriculture to address to reverse the downward trend of student enrollment of agricultural programs. They included: establishing a task force on youth development in and about agriculture to draft a plan to implement this new college priority; request new campus resources an reallocate existing resources within Colleges of Agriculture to initiate this programmatic thrust in college; involve all academic units of the colleges in assuming appropriate roles and responsibilities for youth development in and about agriculture as a coordinated, high- priority initiative in each state; develop a five-year plan for institutionalizing youth development as a major college priority. He concludes that a strong commitment to youth

development would be a significant step in increasing the number of student enrolling in

Colleges of Agriculture.

In 2009, Roberts and Ball examined the philosophical issues regarding the purpose of agriculture in agricultural education. They explored content- centered perspective, behaviorism, advanced skill acquisition theory, the novice – to – expert theory, constructivism, and experiential learning theoretical frameworks to synthesize both content based and context based conceptual models. In conclusion, the authors posit that both models are relevant and appropriate for contemporary agricultural education. A final conceptual model was created which included concepts from both of the individual models and included both outcomes of a “skilled agricultural workforce” and “successful lifelong learners that are agriculturally literate citizens.”

In 1992, Boyd et al. conducted a survey to determine if youth involved in 4-H reported being more confident in their life skills than their non 4-H peers. A total of 309

4-H members and 558 non-4-H members in Texas completed the survey which consisted of 21 life skill statements that were adapted from the Leadership and Development

Inventory developed by Iowa State University. 4-H members also completed questions regarding their level of participation in 4-H which included none, club, county, district, state, and national. The 4-H members reported significantly higher score for all life skill categories (working with groups, understanding self, communicating, making decisions, and leadership). In the second portion of the survey, 4-H members that reported being more involved in 4-H activities reported having higher perceived development of

leadership life skills. This study indicates that 4-H programming in Texas is achieving its goal of preparing youth for adulthood.

Summary

It has been well documented that humans become infected with swine origin influenza A viruses, albeit rare. However, since 2011 the number of reported cases has increased significantly over the previous decade, with a present total of 425 cases (CDC,

December 1, 2017). A majority of these cases have been associated with agricultural exhibitions, leading many public health officials to call for the end to swine exhibition.

Due to the importance of agricultural education to the next generation of pork producers, mitigation strategies need to be developed and disseminated to ensure the continuation of youth livestock exhibition. Many studies have been conducted to develop effective training programs to increase understanding of health risks. In addition, researchers continue to develop learning theories to guide educational efforts. Virology data needs to partner with learning theory to develop educational programming to increase awareness of zoonotic disease risk, thus potentially reducing IAV transmission between animals and people.

The studies outlined in the following chapters have been developed to utilize what is known about effecting learning via constructivist learning techniques to develop educational programming for youth swine exhibitors regarding the risks and mitigation of zoonotic diseases; namely influenza A viruses. Educating youth about the risk of zoonotic disease is an important animal and public health concern as nearly three out five 30

new human illnesses are zoonotic. Animal and public health experts must work alongside extension educators to create and implement programming that is effective and engaging.

Building a repertoire of mitigation strategies based on scientific evidence is a key component to the development of sustainable educational programming. Relying on a trickle-down effect for knowledge dissemination may not be effective for preventing disease transmission between youth and animals, therefore efforts must be focused toward leading transition directly within this group.

Chapter 3: Educating youth swine exhibitors on influenza A virus transmission at agricultural fairs

Research Questions 1 & 2

1) How do youth swine exhibitors‟ knowledge about IAVs change when

participating in scenario-based training exercises?

2) What predictor variables determine IAV knowledge through scenario-based

training exercises?

Summary

Influenza A virus (IAV) is a major zoonotic pathogen that threatens global public health. Novel strains of influenza A viruses pose a significant risk to public health due to their pandemic potential, and transmission of influenza A viruses from animals to humans is an important mechanism in the generation and introduction of IAVs that threaten human health. The purpose of this descriptive-correlational study was to develop real-life training scenarios to better inform swine exhibitors of the risks they may encounter when influenza A viruses are present in swine. Educational activities were implemented in five Ohio counties where exhibition swine had historically been shedding influenza A viruses during the county fair. A total of 146 youth swine exhibitors participated in the educational program, and an increase in the knowledge base of these youth was documented. It is expected that educating youth exhibitors about exposure to influenza A virus infections in the swine they are exhibiting will result in altered

behaviors and animal husbandry practices that will improve both human and animal health.

Background

Influenza A virus (IAV) is a major zoonotic pathogen that has altered the course of human history and continues to threaten global public health and economies worldwide. Annual respiratory disease caused by endemic seasonal strains of IAV significantly burdens the United States‟ health care system by hospitalizing nearly

200,000 people and causing an estimated 36,000 deaths each year (Smith et al., 2006). In contrast to seasonal IAV strains, novel strains of IAV pose a larger and more somber risk to public health due to their pandemic potential. By introducing new viruses and viral gene segments into the human population, animal to human transmission of IAVs is an important mechanism in the emergence of novel IAVs that threaten public health (Reid &

Taubenberger, 2003; Webster, 2002).

Due to its segmented RNA genome, IAV is prone to ongoing and sometimes rapid evolution occurring through both antigenic drift and antigenic shift. Unlike the gradual antigenic drift that occurs through accumulating mutations in the viral genome, a major antigenic shift resulting from genomic reassortment will allow for a swift emergence of a novel IAV. IAVs are capable of infecting many hosts including humans and swine. Pigs have been called „mixing vessels‟ for IAVs because swine-, human-, and avian-lineage

IAVs have resassorted in swine, possibly due in part to the receptors in their respiratory tract (Ma et al., 2008). Reassortment between IAV strains is common in North American

swine populations and a novel strain generation can occur if a pig is simultaneously infected with multiple IAVs (Ito et al., 1998). Novel IAVs which are produced via genetic reassortment in pigs could potentially be maintained in the swine population and/or transmitted to another host species, which makes swine a source for novel IAVs infecting humans (Webby et al., 2004).

While zoonotic transmission of IAVs between pigs and people had been reported periodically (Myers et al., 2007) during the 20th century, the unprecedented number of zoonotic transmissions documented during the H3N2 variant influenza A virus (H3N2v) outbreaks of 2011-2014 garnered attention from public and animal health officials. Close contact between host species, as occurs between swine and humans at livestock exhibitions, allows for zoonotic transmission of IAVs. With an estimated 150 million people attending agricultural fairs in North America each year (International Association of Fairs & Expositions, personal communication) more humans are likely exposed to swine at agricultural exhibitions than at any other livestock exhibitions. Fairs and exhibitions allow people who typically wouldn‟t have swine exposure to have direct and indirect contact with pigs and their potentially zoonotic pathogens.

Unlike commercial swine production, agricultural fairs and exhibitions are unique animal concentration points where pigs from backyard and commercial production systems are comingled on one site for an extended period of time (3-10 days). Factor in the large number of people who are exposed to pigs at fairs, and it becomes apparent that the swine-human interface at fairs has increased potential for zoonotic transmission of influenza A virus (Bowman, 2012). During 2012, 306 cases of variant H3N2 (H3N2v)

were documented (Jhung et al., 2013) with thousands more believed to have gone unreported (Biggerstaff et al., 2013). Most of the people who became infected with

H3N2v had swine exposure at agricultural fairs and livestock exhibitions (Epperson et al.,

2013). Data from the H3N2v outbreaks showed that children had higher risk of infection with H3N2v, which is particularly concerning because the vast majority of pigs are exhibited as part of youth agricultural education programs (Epperson et al., 2013). While human-to-human transmission of H3N2v has been limited to date, people infected at fairs may serve as a pathway to transmit swine-origin IAVs in their local community (Saenz et al., 2006).

Transmission of IAV between swine and humans is not unidirectional and also occurs when humans transmit IAV to swine. The repeated introductions of human- lineage IAVs into the swine population is believed to be responsible for the majority of the genetic diversity in current swine-lineage IAVs (Karasin et al., 2006; Olsen, 2002;

Vincent et al., 2009). As seen after the emergence of the 2009 H1N1 pandemic virus, novel IAVs introduced to the swine population dramatically impacted the financial stability of the pork industry due to export restrictions, increased health costs, and decreased consumer confidence.

Ohio is unique in the ability to study zoonotic IAV transmission at fairs because an active IAV surveillance program was established in Ohio during 2009 to monitor pigs at fairs. The results of this ongoing project show that, on an annual basis, approximately

25% of Ohio fairs have pigs shedding IAV by the conclusion of the fair (Bowman et al,

2012). Among the fairs where there are pigs shedding IAV, the estimated prevalence of

IAV infection in the swine population is >66%, indicating the viral burden in these settings is high. Furthermore, the majority of IAV infections among swine at fairs are subclinical, making it difficult to identify and remove infected animals.

Agricultural education programs serve as a way to introduce youth to swine production and establish an interest in the industry. Many of the youth who participate in these programs pursue careers in agriculture, either in food production or a subsidiary.

Therefore, increasing awareness of the risks posed by zoonotic diseases to these youth programs could improve animal and human health now and into the future. The work presented herein is part of a multi-state, CDC pilot project to prevent transmission of variant influenza and other zoonotic diseases via partnership with youth agriculture organizations.

Methods and Materials

Five Ohio counties were chosen for this study based on their previous participation in IAV surveillance in exhibition swine, and for their total number of youth swine exhibitors. The study team coordinated with local county extension educators to add scenario-based training to already existing quality assurance programs. The team also scheduled specific workshops in which swine exhibitors could participate in the research study. The research design and instrumentation was approved by The Ohio State

University Institutional Review Board protocol number 2015B0007.

Curriculum Development

Real-life scenarios related to IAV in swine were previously developed by the

Ohio Department of Health for use as tabletop exercises during zoonotic training sessions attended by public health professionals, emergency planning personnel, local agricultural extension educators, and veterinary emergency responders. These scenarios, originally written for public health professionals, were modified into youth-appropriate curriculum highlighting swine management practices that should be implemented before, during, and after agricultural fairs for the purpose of reducing the transmission of IAVs between pigs and people.

Scenarios were presented to youth swine exhibitors at educational training sessions weeks prior to the respective county fair, in conjunction with quality assurance training activities. Each educational session began with the administration of a pre-test to gauge prior knowledge of swine exhibitors on IAV and zoonotic transmission and to gather information regarding their IAV vaccination status and swine exposures.

Exhibitors were then presented with IAV basic information and the risks presented by viral infection. After a brief power point introduction, students were divided into small groups to complete scenario activities. Upon completion of the scenarios, groups reported their thoughts to the group as a whole for each question (Appendix 1.) Following the group activity, participants received an overview of biosecurity procedures they should implement to reduce the risk of IAV transmission. To conclude the session, a post-test instrument was administered in the same manner as the pre-test and a question-answer

period followed. Because the pre- and post-test instruments were voluntary, not all participants who completed the pre-test completed the post-test following instruction.

Instrumentation

Pre- and post-tests were used to measure participant knowledge gained. The tests consisted of 20 statements regarding IAV in swine (Appendix 2, 3). Example instrument questions included: I have heard of influenza A viruses, I know pigs can get influenza A viruses, I know what the “H” and “N” mean in the name of influenza A viruses.

Each item was rated on a five-point Likert- type scale to reflect the level of support respondents perceived for each statement (1 = No 2, 3; 4 = Maybe; 5 = Yes). No demographic information was collected to avoid obtaining consent.

Validity and reliability of Instrumentation

Face and content validity were established by a review of a panel of agriculture education experts. Panel members with expertise in virology and agricultural education reviewed the instrumentation to ensure the content measured characteristics it was intended to measure; content validity. All panel experts reviewed for face validity, or the overall appearance of the instrument. Panel of Experts included:

1. Dr. Andrew Bowman – Virology and veterinary medicine expert to assess

scientific background

2. Dr. Scott Scheer – Agriculture Education and 4-H youth development to assess

age appropriateness

3. Ms. Megan Moore – Early Education Teacher to assess reading level

4. Dr. Susie Whittington- Agriculture Education to identify areas in which the

instrument does not gather information to meet study objectives.

To establish reliability of the instrument, a pilot test was conducted during a field test with eight members of a 4-H club in a non-participating county in 2015. The pre-test instrument was administered; members participated in the scenario-based training, followed by post-test administration. Because the pre-test and post-test instruments used

Likert-type scales to measure gain of knowledge, Cronbach‟s alpha was used to estimate internal consistency. The estimated reliability of the pre-test instrument was determined to be 0.84 and the reliability of the post-test instrument was determined to be 1.0.

Study Sample

Youth swine exhibitors in five Ohio counties (Clinton, Butler, Gallia, Licking, and Morrow) were the target population for this scenario-based training. Youth were ages

8-18, enrolled in 4-H and/or FFA, and required to participate in Quality Assurance programming because they had enrolled in a swine production 4-H and/or FFA project.

Data Analysis

Statistical analysis was conducted using IBS SPSS Statistics version 23.

Descriptive statistics were calculated for the following pre-test statements because pre and post test scores should remain unchanged: (9) I get a flu vaccination each year, (10)

My pigs have been vaccinated for influenza A viruses, (11) I have more than one pig at home. Paired samples t-test was used to determine whether or not there was a significant increase in knowledge based on the pre- and post-test scores. Linear regression was applied to determine if pre-test scores, flu vaccination status, pig vaccination status, and having more than one pig at home could account for variation in post-test scores.

Results

Research question 1: How do youth swine exhibitors‟ knowledge about IAVs change when participating in scenario-based training exercises?

A total of 146 youth swine exhibitors participated in the training program during the spring/summer of 2015. The participation varied among the five counties, with county

C having the most participants (n=75) and county E having the fewest (n=6).

Of the 146 participants, 124 (85%) completed both pre- and post-tests during the training activity. The post-test mean score of 87.3 was significantly (α=0.05) higher than the pre-test score of 65.6. (p<.001) See table 1.

Table 1. Knowledge scores at pre- and post-test assessments

Knowledge scores (mean±SD) Pre-test Post-test Items t p< score score 3.46 ± 4.56 ± 1. I have heard of influenza A viruses -5.8 0.001 1.68 1.14 3.73 ± 4.77 ± 2. I know pigs can get influenza A viruses -6.85 0.001 1.46 0.76 3. I know what the “H” and “N” mean in the name 1.96 ± 3.77 ± -8.23 0.001 of influenza A viruses 1.43 1.6 4. I know how influenza A viruses spread between 3.05 ± 4.55 ± -7.58 0.001 animals 1.66 1.07 5. I know how influenza A viruses spread between 4.52 ± 2.74 ± 1.7 -8.4 0.001 animals and people 1.1 6. I know what to do before the fair if my pig 3.73 ± 4.71 ± -6.67 0.001 seems sick 1.47 0.84 7. I know what to do at the fair if my pig seems 3.58 ± 4.63 ± -6.33 0.001 sick 1.59 0.95 8. I know what to do after the fair if my pig comes 4.49 ± 3.58 ± 1.7 -4.8 0.001 home with me 1.14 3.59 ± 9. I get a flu vaccination each year 3.33 ± 1.8 -2.26 0.05 1.74 10. My pigs have been vaccinated for influenza A 2.87 ± 3.39 ± -3.04 0.05 viruses 1.67 1.78 3.96 ± 4.34 ± 11. I have more than one pig at home -3.56 0.001 1.74 1.45 12. I have a veterinarian that I can call if my pig is 3.81 ± 4.27 ± -3.25 0.001 sick 1.68 1.45 4.24 ± 4.51 ± 13. I have animals other than pigs at home -2.06 0.05 1.51 1.27 2.88 ± 4.06 ± 14. I know how to take a pigs temperature -6.17 0.001 1.76 1.52 2.22 ± 4.29 ± 15. I know the clinical signs of influenza in pigs -9.17 0.001 1.56 1.45 16. I am confident in my ability to tell when a pig 3.38 ± 4.5 ± -7.24 0.001 is sick 1.54 1.02 3.25 ± 4.67 ± 17. I have had influenza infections before (the flu) -7.53 0.001 1.88 0.97 4.05 ± 4.7 ± 18. I know who to talk to if I think I have influenza -4.02 0.001 1.57 0.88 19. I know what factors make it more risky for 2.97 ± 4.51 ± -8.06 0.001 humans to visit pig barns 1.68 1.12 2.75 ± 4.36 ± 20. I know what the term bio-security means -7.87 0.001 1.78 1.32

Research question 2: What predictor variables determine IAV knowledge through scenario-based training exercises?

Linear regression was used to calculate that 18% of the variance in post-test scores was accounted for by the pre-test score when controlling for human vaccine status

[57/124 (46%)], swine vaccine status [34/124 (27%)], and more than one pig on the premise [90/124 (73%) (p<.001).

Table 2. Regression table accounting for variance in post-test scores

Unstandardized Standardized Collinearity Statistics Coefficients Coefficients t Sig. Std. B Beta Tolerance VIF Variable Error (Constant) 96.607 4.524 21.352 0.000 Total Pre-test score -0.270 0.058 -0.397 -4.668 0.000 0.956 1.046 "I get a flu vaccine each year" 0.232 0.613 0.032 0.379 0.705 0.965 1.036 "My pigs are vaccinated for IAV" 1.232 0.719 0.158 1.713 0.089 0.818 1.223 "I have more than one pig at home" 1.033 0.695 0.138 1.486 0.140 0.798 1.254 a. Dependent Variable: Post Test Total Score

Discussion

In the present study, researchers were specifically concerned with developing materials considered to be a tool in Engerstrom‟s conceptual framework, based on the

Activity Theory (Nardi, 1996). The tool was defined by Jonassen as anything used in the transformation process which shapes the way people think and act. In this study, the tool was the scenario-based training model used to teach swine youth exhibitors about the risks associated with IAVs and the mitigation strategies used to prevent infection.

(Jonassen,1999).

The Activity Theory was supported in this current study with measurable perceived gain of knowledge by participants after completing hands-on activities in which they were actively engaged. To demonstrate one way viruses spread, a toy pig was covered with glitter prior to the training and then passed to each participant during the introduction. Following the circulation of the pig, participants were made aware of the glitter that had been left behind on their hands, clothes, faces, and other belongings, which simulated the transmission of IAVs from pigs to humans and between humans.

Participants grasped the concept of viral transmission through this demonstration, as indicated by increase in post test scores for the question, “I know how influenza A viruses spread between animals” and for the question, “I know how influenza A viruses spread between animals and people”.

Following the administration of the tool, researchers investigated outcomes by measuring the prevalence of IAVs in swine compared to previous years. The five counties where training sessions were held had 60% tested pigs shedding IAV in 2013,

19.57% in 2014, and 0% in 2015 (year training occurred) as compared to IAV recovery rates of 31% in 2013, 30% in 2014, and 13.5% in 2015 for all fairs enrolled in swine surveillance (Bowman, unpublished data). Each year, samples were collected on the last day of the exhibition period, with no fairs requiring vaccination prior to the fair. In both

2014 and 2015, H3N2 was the predominate subtype shed from exhibition swine included in this study. Although this training tool is not the only variable that affects prevalence of pigs shedding IAV, it was notable considering the years of previous data.

Implementing swine exhibitor training in select counties led to an increase in the knowledge of youth regarding zoonotic disease as determined by significant increase in post-test scores as compared to pre-test scores. Data from this pilot study can guide educators in implementing future training activities for swine and other livestock exhibitors. The continuation of training programs can be beneficial for improving animal and public health today and into the future.

Citation for above work: Nolting, J. M., Midla, J., Whittington, M. S., Scheer, S. D., &

Bowman, A. S. (2017). Educating youth swine exhibitors on influenza A virus transmission at agricultural fairs. Zoonoses and public health, 65 Suppl 1, S1-5.

Chapter 4: Swine Zoonotic Disease Risks and Prevention

Research Question 3

Has the dissemination of the “Swine Zoonotic Disease Risks and Prevention” chapter of the Swine Resource Handbook been effective?

Summary

One of the most valuable tools given to youth 4-H and FFA exhibitors to complete their livestock project is project record books and resource handbooks. The

Swine Recourse Handbook, given to all youth who enroll in a swine production project in the state of Ohio, contains in-depth materials on several subjects relating to swine management. Although there is a chapter on swine diseases in the handbook, there is no mention of biosecurity, personal protective equipment, or zoonotic diseases, which are necessary topics to reduce the risks of disease transmission between pigs and between pigs and people. In collaboration with the Ohio 4-H curriculum development team, content regarding the risks associated with swine zoonotic diseases was compiled into a seven-page book chapter to be included in the Swine Resource Handbook. In order to evaluate the effectiveness of the handbook chapter, a skill-a-thon station was developed to test the knowledge of youth exhibitors regarding the information contained in the chapter. A total of 48 (24%) participants in the Ohio State Fair Swine Skill-a-thon completed the zoonotic disease station as a tiebreaker. The scores for the zoonotic disease tiebreaker station were not statically different from that of the standard stations. This

performance indicates that the dissemination methods used for the zoonotic disease risk and management chapter was as effective as if it were in included in the Swine Resource

Handbook because participants scored similarly when asked about material covered in the handbook. Inclusion in skill-a-thons can encourage participants to become familiar with zoonotic disease transmission prevention which could prevent variant influenza A virus cases associated with agricultural fairs.

Background

One of the most valuable tools given to youth 4-H and FFA exhibitors to complete their livestock project is project record books and resource handbooks. These resources contain information pertaining to the specific livestock species project the youth is enrolled in to give them the knowledge needed to successfully raise animals. The project books contain information related to choosing an animal, breeds of the species, nutritive requirements of the animal, proper animal housing, animal health, and animal products. There are also areas for youth to keep records of feed consumption, medication usage, and costs associated with raising the animal to teach proper record keeping procedures. The Swine Recourse Handbook given to all youth who enroll in a swine production project in the state of Ohio contains in-depth materials on several subjects relating to swine management. Although there is a chapter on swine diseases in the handbook, there is no mention of biosecurity, personal protective equipment, or zoonotic diseases, which are necessary topics to reduce the risks of disease transmission between pigs and between pigs and people.

Methods and Materials

Instrumentation

In collaboration with the Ohio 4-H curriculum development team, content regarding the risks associated with swine zoonotic diseases was compiled into a seven- page book chapter to be included in the Swine Resource Handbook. The chapter begins by defining what a zoonotic disease is and how they spread. Next, recommendations for preventing disease transmission between pigs and people are described, including proper hand washing techniques. Because the resource handbook is geared toward youth swine exhibitors, specific mitigation strategies associated with exhibition practices are categorized by before, during, and after exhibition. The last section of the chapter lists several common zoonotic diseases found in swine. Signs of clinical illness in swine and humans are described along with proper personal protective equipment that should be used to prevent disease transmission. See Appendix B for chapter.

In 2017, the chapter was disseminated to youth swine exhibitors as an addendum to the Swine Resource Handbook through online 4-H and extension resources. Paper copies of the chapter were disseminated to youth participating in face-face training sessions hosted by Animal Influenza Ecology & Epidemiology Research Program team members. The chapter will be incorporated into the next edition of the printed Swine

Resource Handbook, expected for the 2019 program year.

Study Sample

Youth swine exhibitors ages 8-18, enrolled in 4-H and/or FFA, and who participated in the 2017 Ohio State fair swine skill-a-thon were the target population for the evaluation of success for the zoonotic disease chapter of the Swine Resource Handbook.

Data Analysis

In order to evaluate the effectiveness of the handbook chapter, a skill-a-thon station was developed to test the knowledge of youth exhibitors regarding the information contained in the chapter. Skill-a-thons are events held at local and state levels to gauge an individual‟s knowledge pertaining to their specific livestock species subject matter using the experiential learning model of exploring, reflecting, and applying knowledge.

Typically the skill-a-thon is divided into several stations, addressing various topics such as feedstuffs, meat cuts, anatomical parts, feed labels, and proper injection sites. As is common with many skill-a-thon stations, the zoonotic disease station will incorporate pictures, phrases, and tangible items that students must identify by matching to complete.

The following topics were addressed:

1. What goes in a biosecurity bucket?

a. Students were given various items recommended to be on hand for

proper biosecurity to prevent zoonotic disease transmission with their

swine project and items that are not recommended. They were asked to

add the proper items to the biosecurity bucket.

2. Which diseases are zoonotic?

a. Cards containing the names of common swine diseases discussed in

the Swine Resource Handbook will be divided by youth participants

into two groups; zoonotic and not zoonotic.

3. How do diseases spread?

a. Participants will be asked to match cards containing the type of disease

transmission (direct contact, airborne, fecal/oral) with the appropriate

description. In addition, participants will arrange disease names with

their proper mode of transmission.

4. What are the clinical signs of zoonotic diseases in humans and swine?

a. Participants were asked to pick both the clinical signs seen in humans

and in swine for zoonotic disease described in the Swine Resource

Handbook.

Youth participants were scored based on the number of items they identify correctly and an overall score was assigned. Sections of the skill-a-thon station were piloted at the 2017

Ohio State fair to assess the reliability of the activities. Upon completion of the pilot, mean scores from participants of the zoonotic disease pilot were compared to mean scores of the established skill-a-thon stations using a t-test calculated in SPSS. Necessary adjustments were made following the pilot and the materials for zoonotic disease skill-a- thon station will be distributed to each of Ohio‟s 88 counties extension offices for use during the 2018 program year.

Results

Dissemination of Chapter

The Zoonotic Disease chapter of the Swine Resource Handbook was made available during the 2017 program year as an individual handout and a downloadable file online. Approximately, 1000 paper copy handouts were distributed at the World Pork

Expo, to all participants in the Ohio swine jackpot circuit, and to all youth who participated in the Becoming a Swientist program. In addition, the chapter was available online on the Ohio 4-H Youth Development Livestock Resources page at the following address https://ohio4h.org/sites/ohio4h/files/imce/Swine%20Zoonotic%20Disease.pdf

Skill-a-thon

In all, 198 youth enrolled in 4-H and/or FFA participated in the 2017 Ohio

State Fair swine skill-a-thon. Each participant completed four stations containing material regarding selection, anatomy, and disease (station 1); biosecurity, medication, and treatment (station 2); feeds and animal care (station 3); meat science (station 4); and a tiebreaker station of equipment and zoonotic diseases (station 5). A total of 48 (24%) participants had total scores either greater than the current high score or no more than five points below the high score and therefore completed the zoonotic disease station as a tiebreaker. The average scores for each station are listed in table 2. The scores for the zoonotic disease tiebreaker station ranged from zero to ten with an average of 5.02 out of

10 (50%), which is not statically different from that of the standard stations (p<0.01).

Table 3. Descriptive statistics for each swine skill-a-thon station from the 2017 Ohio State Fair.

N Range Minimum Maximum Mean Std. Deviation Tiebreaker-Diseases 48 10.00 .00 10.00 5.0208 2.90626 Station 1 Total 198 23.00 2.00 25.00 14.0152 5.59775 Station 2 Total 198 23.00 .00 23.00 13.6010 5.00126 Station 3 Total 198 22.00 3.00 25.00 14.5909 6.30279 Station 4 Total 198 23.00 .00 23.00 10.5101 4.74394

Discussion

Utilizing resource handbooks available to all 4-H and FFA swine youth exhibitors allowed for wide distribution of information regarding zoonotic diseases in swine and how to prevent disease transmissions. Educators are unable to host scenario based training sessions to accommodate all youth swine exhibitors in the state of Ohio, although all are at risk of being exposed to swine-origin influenza A viruses. Therefore, wide dissemination of information with low input costs is imperative to extending the knowledge base to prevent disease transmission between people and pigs. Including the

“Swine Zoonotic Disease Risks and Prevention” in the next edition of the Swine

Resource Handbook is the ultimate goal of this project, however the next revision is not planned until at least program year 2019. Because the new handbook is not ready for print, alternative dissemination methods had to be used.

Relying on website downloads and passing out paper versions of the chapter at training events was likely not as effective as having the information included in the resource handbook. Therefore an evaluation tool was needed to measure the effectiveness of the dissemination methods used. Because this study was designed using activity theory 51

as the theoretical framework, it was designed to use a skill-a-thon activity to measure the effectiveness of the static, written information. Authentic assessment uses observation, conferencing, self-evaluation, and/or collaborative evaluation to measure the knowledge gained by participants using tasks, rather than recalling information stored in short term memory (Cole, 1994). Skill-a-thon activities allow extension professionals flexibility in evaluating the knowledge obtained by youth throughout the duration of their projects and this real-life evaluation helps youth connect to their education (Cole, 1994). Not only does authentic assessment allow youth to connect to their education through real-life settings, but it also allows them the opportunity to take control of their education. Youth can choose how they prefer to learn the expected knowledge and how they will demonstrate the skills they have acquired (Barnett, 1992). This flexibility allowed for zoonotic disease risk and prevention information to be included in the Ohio State Fair skill-a-thon.

Participants who completed the zoonotic diseases station had average scores of only 50%, however these averages were not statistically different from the scores achieved on the other stations. This performance indicates that the dissemination methods used for the zoonotic disease risk and management chapter was as effective as if it were in included in the Swine Resource Handbook because participants scored similarly when asked about material covered in the handbook. Authentic assessment was achieved by this skill-a-thon event because participants were asked to move between stations to demonstrate knowledge across broad topic areas (Black & Black, 1997). The skill-a-thon at the Ohio State Fair is designed to be challenging for participants with a focus on being

competitive, and therefore could have resulted in lower scores for the material covered in traditional stations. However, authentic assessment is designed to assess participants‟ ability to solve problems, react to situations similar to that of their learning experiences, and to reflect upon the knowledge gained (Darling-Hammond & Snyder, 2000).

Nonetheless, information covered in the skill-a-thon is available to participants to study if they so choose. If participants chose to not prepare for the skill-a-thon, scores are based on their previous knowledge which may be the case for both the traditional stations and the zoonotic disease station. In addition, participants in the Ohio State Fair skill-a- thon are likely more versed in the exhibition swine industry and may have more experience and knowledge regarding swine health and production than their counterparts who participate only at the local level.

Utilizing performance in the skill-a-thon to evaluate the effectiveness of the zoonotic disease chapter of the Swine Resource Handbook was flawed in several regards; however it could prove to be an effective evaluation at local levels. After the chapter is incorporated into the new edition of the Swine Resource Handbook, the skill-a-thon station could be incorporated into individual county skill-a-thon events to evaluate the knowledge of local showman. Since most H3N2v cases have been associated with local county-level agricultural fairs, it is imperative that information regarding the prevention of zoonotic disease transmission reach youth at this level. Inclusion in skill-a-thons can encourage participants to become familiar with zoonotic disease transmission prevention which could prevent variant influenza A virus cases associated with agricultural fairs.

Chapter 5: Becoming a Swientist

Research Question 4

How did the “Becoming a Swientist” Program influence the healthy habits of swine exhibitors?

Summary

Many of the youth involved in showing pigs at jackpot shows are not involved in youth agricultural organizations because these shows are independent swine exhibitions open to all swine producers to advertise the quality of animals they produce and do not have stringent age limits for showmen. Developing educational programming to target this population could be beneficial in disseminating information to individuals who are heavily involved in the show pig industry. Hands-on learning activities based on constructivist learning theories were developed and introduced to increase awareness of the animal and human health risks associated with IAVs circulating in the exhibition swine for these jackpot showmen. In order to measure participation, a website

(www.go.osu.edu/swientist) was designed for youth to upload selfies of them practicing healthy habits, as was demonstrated in the learning activities. In all, ten youth created profiles and uploaded 37 selfies of them practicing healthy habits to prevent the spread of zoonotic diseases. Based on the photos submitted the most frequently practiced healthy habit is footwear disinfection, followed by equipment disinfection. Other healthy habit photographs submitted included hand hygiene, veterinary checks, animal washing, 54

biosecurity bucket usage, and isolation of swine following a show. These photos are evidence that participants in the “Becoming a Swientist” training program were not only introduced to the recommended biosecurity and infection control procedures, were able to apply their newly gained knowledge at their own farms.

Background

The above mentioned activities only target youth involved in youth organizations such as 4-H and FFA, however many of the youth involved in showing pigs at jackpot shows are not involved in these agricultural organizations because these shows are independent swine exhibitions open to all swine producers to advertise the quality of animals they produce and do not have stringent age limits for showmen. Developing educational programming to target this population could be beneficial in disseminating information to individuals who are heavily involved in the show pig industry.

Methods and Materials

Training Events

The development of hands-on learning activities based on constructivist learning theories was completed and introduced to increase awareness of the animal and human health risks associated with IAVs circulating in exhibition swine for jackpot showmen.

Youth jackpot exhibitors, ages 3-21, took part in the “Becoming a Swientist” program in which they completed a mucus swap activity; practiced proper hand washing techniques;

assembled bio-security buckets; and received basic information for implementing biosecurity on their farms (Appendix E). “Becoming a Swientist” activities were held at Hog

Wild at Hartford Swine Jackpot show, in Croton, Ohio in May, 2017.

At the Croton event, participants were divided into two groups, ages 12 and under and ages 13 and older. The interest approach used with both groups was a mucus swap activity in which participants were given small cups containing approximately 30ml of distilled water. One cup in each group had the water pH adjusted to >7 using sodium carbonate (Ricca item #7175-16); however the cup was unmarked and all water remained clear. Students were told each cup represented a pig and one of the pigs was infected with influenza A virus, however they couldn‟t decipher which was positive by looking at the cups. Just as pigs touch snouts when they encounter another pig, participants poured water from their cup into another participant‟s cup. They then poured half of the fluid back into the empty cup and found another participant to swap with until each had swapped three times. Once all swapping had occurred, program leaders added two drops of Phenolphthalein solution R, 0.1% (Ricca item# 5598-32) to each cup, which changes the color of water with pH>7 to bright pink, indicating the influenza A virus positive pigs in the scenario. Students were challenged with the task of determining the original positive pig by tracing back the individuals who swapped fluid.

At the conclusion of the mucus swap, participants were introduced to zoonotic diseases. Brief explanations of how disease spread between and examples of zoonotic diseases followed. Next, biosecurity was introduced with concepts of how to protect animal and human health not only on the farm, but also at swine exhibitions. Following

the discussion, each participant assembled a Biosecurity Bucket that they could take with them to use as an example of biosecurity practices they could implement on their own farms. The Biosecurity Buckets contained the following items with appropriate instructions for use:

1. Bucket: Hold all supplies together and mix liquid disinfectant or use for rinse water.

2. Soap: Wash all animal care supplies before and after attending a show. Wash hands anytime you have animal contact.

3. Scrub brush: Scrub off all debris when washing supplies and boots.

4. Disinfectant: Disinfect all animal care supplies and boots after they have been cleaned.

5. Protective Clothing: Wear coveralls or barn clothes whenever you have animal contact.

Change immediately following being in the barn.

6. Gloves: Protect your hands from infectious disease by wearing gloves when you work with animals; especially if they are sick.

7. Boot covers/Rubber Boots: Have rubber boots to wear in the barn. Clean and disinfect regularly. Have visitors wear boot covers to enter your barn.

8. Face Mask: Protect yourself from inhaling infectious disease when in contact with ill pigs.

In addition to the Hog Wild at Hartford event, “Becoming a Swientist” programming was completed at the World Pork Expo in Des Moines, Iowa during June

2017. A booth was set up in the exhibitor‟s merchant building for the duration of the expo in an effort to connect with jackpot exhibitors, to gain trust for future educational programming. Portable hand wash stations were present for the entire expo for youth to

wash their hands before taking a free freezer pop. Besides hand hygiene lessons, there was a different game or short activity each day of the event. Activities included the mucus swap game, crossing a clean/dirty line practice, assembling biosecurity buckets, testing pigs for flu demonstration, and hand washing techniques using glo germ. There was also an IPad station for older youth to complete the “Excellence in Exhibition:

Preventing Disease in Animals and People” online course hosted by Iowa State

University.

Study Sample

Youth jackpot exhibitors, ages 3-21, who were participating in the 2017 OH-Pigs

Jackpot circuit were the target population to address this research question. To entice individuals to participate, points were awarded for every selfie uploaded and winners in each OH-pigs showmanship age division received IPads for their efforts. Second place individuals received custom scarlet and gray show sticks for their participation. To compete for awards, selfies had to be submitted by July 15, 2017 and the awards were distributed at the OH-Pigs Annual Banquet on August 18, 2017.

Data Analysis

In order to measure participation, a website (www.go.osu.edu/swientist) was designed for youth to upload selfies of them practicing healthy habits, as was demonstrated in the learning activities. Individuals created an account which required

user name, password, full name, address, years exhibiting pigs, birthdate, shirt size, and included approved IRB consent verbiage to gain permission to use the selfies in this research project (OSU IRB protocol #2017B0185). Upon completing the registration process, regardless of whether participants agreed to the research project, they were directed to a page to upload selfies and create captions for the photos. Users were only able to access their own photos and comments, and could log in to upload photos as many times as they wish.

Upon completion of the program, descriptive analysis was completed to determine the frequency of each healthy habit being displayed by youth in the photos they submitted. Content analysis was used with this qualitative data to gain insight into the adoption of healthy habits by youth swine exhibitors.

Results

Hog Wild at Hartford

In all, approximately 35 youth ages 3-21 participated in the Becoming a Swientist program event at the Hog Wild at Hartford jackpot swine show. Show organizers used

Facebook Live to capture the event, which has been viewed 866 times as of February 3,

2018. All youth participated in the mucus swap game and engaged in conversation following the game to determine which “pig” was initially infected. Next, disease transmission routes were discussed, along with examples of zoonotic diseases found in swine. The Swine Zoonotic Disease Risk and Prevention handout was provided to each youth participant to follow along with material being covered by the presenter. After the 59

short discussion, each participant assembled a Biosecurity Bucket to take home as a reminder of proper biosecurity procedures at their home farms. At the conclusion of the training, participants were given instructions for posting selfies and taking part in the research study.

World Pork Expo

The World Pork Expo, hosted by the National Pork Producers Council, was held

June 5-9, 2018 in Des Moines, Iowa. Over 450 companies from around the world displayed products and services to over 20,000 pork producers and agricultural professionals from over 40 countries across the world. The World Pork Expo Junior

National swine show attracted 1,350 youth from 32 states, who registered 4,300 pigs to compete at this prestigious exhibition. The “Becoming a Swientist” booth distributed

5,000 Freeze Pops (450lbs of frozen sugar water), 1,000 biohazard buckets, and over

1,000 Swientist stickers and other handouts. Youth were participating in activities nearly non-stop from 9am – 6pm each day of the event, with several stopping at the booth multiple times each day. Figure 1 describes “Becoming a Swientist “activities and participants at World Pork Expo.

Figure 3. Photos from "Becoming a Swientist" at World Pork Expo

The “Becoming a Swientist” booth at the

World Pork Expo was a 30‟x10‟ area that

was arranged differently each day to

accommodate changing activities.

The Becoming a Swientist booth became a

favorite hang out for seveal youth

participants during the week. They lent a

helping hand preparing for the day‟s

activities and encouraged other youth to

take part in the fun.

Continued from page 61

Four portable hand wash stations were

present for the duration of the event.

Youth had to was their hands before

taking a freezer pop; no matter how long it

had been since their last frozen treat.

Jackpot swime shows, including the Junior

show at World Pork Expo, are for youth

aged 3 – 21 years.

Many of the activities hosted at the Becoming a

Swientist booth at World Pork Expo were centered

around concepts of biosecurity. One activtity

included youth learning to cross a clean/dirty using

a procedure acceptable in most commerical swine

facilities. After youth donned appropriate personal

protective equipment (PPE), they washed their

hands, and received a Freeze Pop.

Continued from page 62

Biosecurity buckets were assembled by

passerbys as a reminder of the types of

measures that should be in place to protect

animal and human health. In all, 1000 kits

wre assembled and distributed.

Because conducting influenza A virus

surveillance at national shows, like World

Pork Expo, is important in understanding

viral ecology, youth were taught how to

collect and test samples from swine using

stuffed pigs and non-infectious laboratory

equipment. Youth collected nasal wipes

from pigs, then traveled to make shift lab

where they donned lab coats and tested

their samples using shame diagnostics

which releyed on pH changes.

Healthy Habits Selfies

In all, ten youth created profiles on www.go.osu.edu/swientist to upload selfies of them practicing healthy habits to prevent the spread of zoonotic diseases. Participants submitted a total of 37 photos during the two month contest period. Based on the photos submitted the most frequently practiced healthy habit is footwear disinfection, followed by equipment disinfection. Other healthy habit photographs submitted included hand hygiene, veterinary checks, animal washing, biosecurity bucket usage, and isolation of swine following a show (see table 4). Figure 2 includes examples of the photos and captions submitted by participants.

Table 4. Frequency of healthy habit categories submitted via selfies

No. of submitted Healthy habit category selfies Disinfection of equipment 17 Participating in "Becoming a Swientist" program 9 activities Changing boots/boot wash 7 Relationship with veterinarian 1 Washing hands 1 Keeping swine clean 1 Isolation of pigs returning home from a show 1

To incentivize participation in the healthy habit selfie program, youth were divided by OH-pig showmanship age categories to compete for prizes. The first place participant in each age division won an IPad with a custom Swientist case. The second and third place participants in each division were awarded custom scarlet and gray show sticks. All awards were distributed at the OH-Pigs annual banquet in August 2017.

Figure 4. A subset of photos and captions of healthy habits submitted by “Becoming a

Swientist” participants.

“Soaking boots in bleach and soap after a

visit to the pig farm.”

“Ali getting her shoes disinfected before

going into the barn with her show pigs”

“I have a pair of Nike flip flops that stay in

show barn. I only wear them in the show

barn so none of my other shoes are

contaminated when dealing with my sows

or in the farrowing house.”

Continued from page 65

“Washing my hands after coming home

from the farm.”

“Pigs getting blood tested to check for

disease before going to a national show.”

“After every show we bleach all

equipment”

Discussion

The Becoming a Swientist program was designed to be an incentivized, educational program to share knowledge regarding zoonotic disease risk and prevention with youth swine exhibitors. Many other animal science and swine production workshops and training events are held each year to aid in the training of youth in agriculture. One example is the Junior Pork day, which is held annually by Purdue University to use hands on learning techniques with 4-H members and their parents to share current issues in the pork industry. Authors reported that first time participants gained the most from 67

attendance with 63-77% of first time attendees having gained knowledge in specific subject areas (Rusk, 2002). Another example of successful animal science training for youth included a three day workshop that allowed participants to interact with university faculty to brainstorm new ideas for improved animal care methods (Rusk, 2002). This training format has impacted over 8,000 youth interested in animal sciences over multiple years. When polled, 94% of attendees reported that the workshop was a positive learning experience (Rusk, 2002). These types of workshops compliment the “Becoming a

Swientist” program because they are targeting 4-H youth, who may or may not be involved in jackpot swine shows.

“Becoming a Swientist” programmatic activities were based on the activity framework whereas the hands on activities are “tools” in the conceptual framework presented in chapter 3 of this document. The 4-H program embraces the “learning by doing” constructivist learning theory, which has been adopted by the Becoming a

Swientist program. Youth were introduced to concepts of biosecurity and disease prevention through hands on activities and practicing procedures on their own. Proper hand hygiene techniques were reinforced through the use of Glo-germ products and the repetition of hand washing each time youth came to the booth for a free freeze pop.

Biosecurity when entering a swine barn was demonstrated by having youth use proper procedures to cross a clean/dirty line. These procedures were again reinforced by having boot covers present in the biosecurity buckets that were assembled by participants. The buckets contained representations of other items needed to implement good biosecurity practices on swine farms. Youth discussed the items and their uses with educators as they

assembled the buckets. Anecdotally, several youth who made biosecurity buckets visited the booth at a later time to ask for additional items, because they used their original set during World Pork Expo. Items that were used during the week included boot covers, disinfecting wipes, and gloves.

Measuring the effectiveness of the hands on activities using the healthy habit selfie uploads was not successful because of the small number of photos submitted. Once the pictures were divided into unique categories, there were not enough in each category to perform a statistical analysis. Broadly, disinfection was the prevention technique most widely adopted by participants based on the content of the selfie uploads. The reason disinfection was more widely adopted over other healthy habits was not determined, however several factors could be responsible. First, disinfection can be fast, inexpensive, and simple procedures for individuals to implement to protect animal health.

Disinfectants, such as bleach, are readily available and the concepts are easily understood. In addition, disinfection requires relatively low input and minimal changes to standard operating procedures. This may be a key component when families choose which healthy habits to adopt, because it can require little effort and have low impact on the families‟ show schedule.

The use of selfies to evaluate the adoption of healthy habits among youth participants was implemented to follow social trends that began with the inclusion of forward-facing cameras on iPhone 4 smartphones. It has been reported by Choi (2017) that millions of social media users post selfies every day (Choi, 2017). The phenomenon has exploded with a reported 50% of men, 52% of women, and 55% of millennials

having shared their selfies on social media networks (Choi, 2017). Submitted photos are evidence that participants in the “Becoming a Swientist” training program were not only introduced to the recommended biosecurity and infection control procedures, were able to apply their newly gained knowledge at their own farms. While disseminating knowledge is purpose of the development of a training program, it is essential to evaluate the effectiveness of the training program. Utilizing modern technology to see participants demonstrating lessons learned through the training program allowed for the evaluation of the key ideas accepted by jackpot showman. This information will be used to further guide the development of future training endeavors.

Chapter 6: Can recommendations for reducing zoonotic transmission of influenza A viruses from swine impact human attitudes and behaviors?

Research Question 5

What were the perceptions and behaviors of jackpot swine exhibitors related to IAV?

Summary

Since 2011, there have been 425 cases of variant influenza A virus (IAV) reported in the United States, many of which were associated with youth swine exhibition. In an effort to mitigate risk associated with exposure to IAV in swine through these events, the recommendation document “Measures to Minimize Influenza Transmission at Swine

Exhibitions” was developed to be used by show organizers, volunteers, and exhibitors.

These recommendations are updated and released each year; however, it is not clear if youth swine exhibitors are aware of the recommendations; support the recommendations; and would be willing to practice recommended behaviors. Therefore, a cross-sectional survey method was used to understand swine exhibitor perceptions and their adoption of swine production practices aimed at reducing the transmission of IAV at the human- animal interface. The instrument created consisted of 11 recommendations put forth in the “Measures…” document. Each statement was followed by three to six statements regarding the participant‟s perception of the recommendation, their opinion of their ability to implement the recommendation, and their current behavior related to the recommendation. In addition, the survey asked participants their state of residence and the number of shows they would attend in 2017. In all, 155 participants who showed 71

swine on a regular basis (x =11 shows per year), from at least 18 states within the US, completed the survey. At least 67% of participants believed each statement was a good recommendation, with 6 of 11 recommendations being supported by >90% of participants. When asked if recommendations could be implemented, 65-94% of respondents agreed, and 21-89% of participants had already implemented each recommendation, respectively. Although significant efforts have been made to increase signage at swine exhibitions warning of risks associated with eating/drinking in animal areas, a majority of respondents report eating/drinking in the barn and are unwilling to change their behaviors. This study provides evidence that developing and disseminating static recommendations to reduce zoonotic disease transmission is not enough to change human behavior and interactive methods must be deployed to preventive future variant

IAV infections associated with swine exhibitions.

Background

Many of the concepts highlighted in the “Becoming a Swientist” program were based upon recommendations presented in the “Measures to Minimize Influenza

Transmission at Swine Exhibitions” document released each year by a committee of animal and public health officials. It is not clear how many youth swine exhibitors were aware of the recommendations; support the recommendations; and would be willing to practice behaviors recommended. Therefore, a cross-sectional survey method was used to understand swine exhibitor perceptions and their adoption of swine production practices aimed at reducing the transmission of influenza A viruses at the human-animal interface. 72

Methods and Materials

Instrumentation

The instrument created consists of 11 recommendations put forth in the

“Measures…” document. Example statements include: Clean and disinfect all tack, feeders, waterers, and show supplies between shows; Wash your hands with soap and water when you leave the barn; and No food or drink in animal areas. Each statement is followed by three to six statements regarding the participant‟s perception of the recommendation, their opinion of their ability to implement the recommendation, and their current behavior related to the recommendation. In addition, the survey asks participants which state they reside, and the number of shows they will attend in 2017

(Appendix C).

Validity of Instrument

Face and content validity were established by a review of a panel of virology experts and young adults involved in public health and agricultural education. Panel members with expertise in virology and agricultural education reviewed the instrumentation to ensure the content measured characteristics it was intended to measure; content validity.

All panel experts reviewed for face validity, or the overall appearance of the instrument.

Panel of Experts included:

1. Dr. Andrew Bowman – Virology and veterinary medicine expert to assess

scientific background 73

2. Ms. Sarah Lauterbach - Virology and veterinary medicine expert to assess

scientific background

3. Dr. Josh Lorbach – Virology and veterinary medicine expert to assess scientific

background

4. Ms. Elena Mircoff – Masters of Public Health Student to assess public health

relatedness

5. Ms. Sarah Nelson – Virology and veterinary medicine expert to assess scientific

background

6. Ms. Hannah Cochran – Young adult involved in agricultural education to

determine age level appropriateness

7. Ms. Rachel Patton– Young adult involved in agricultural education to determine

age level appropriateness

Study Sample

Surveys were collected from jackpot swine exhibitors, ages 3-21, regarding their perceptions and behaviors related to recommendations in the “Measures to Minimize

Influenza Transmission at Swine Exhibitions” document.

Data Analysis

Deductive reasoning was used to determine if themes of support in accordance with recommendations exist among swine jackpot exhibitors. Content analysis was used to gain insight in the perceptions and behaviors of jackpot swine exhibitors. Frequencies were calculated using SPSS and used to compare the number of shows attended and the state distributions of respondents.

Results

In all, 155 jackpot show participants in the OH-Pigs jackpot circuit, the

Showpigs.com All-Star camp, and World Pork Expo who showed swine on a regular basis (x =11 shows per year), from at least 18 states within the US, completed the survey

(Table 5). At least 58.7% of participants believed each statement was a good recommendation, with 5 of 11 recommendations being supported by >85% of participants. When asked if recommendations could be implemented, 54-82% of respondents agreed, and 36-93% of participants had already implemented each recommendation, respectively. Recommendations that have been widely adopted by respondents include; avoidance of sick pigs or people attending shows (90%) and disinfecting equipment between shows (88%). The recommendations not being implemented commonly by respondents include; not eating and drinking in animal areas

(19%), reporting sick pigs to show organizers (36%), and isolating animals when they are taken home after a show (45%). Details for the responses to each survey item are listed in

Table 6.

Table 5. Number of survey respondents representing each state included in the study.

State No. Surveys

Arkansas 2

Arizona 5

California 1

Florida 4

Georgia 2

Iowa 1

Idaho 1

Illinois 2

Indiana 4

Kansas 1

Michigan 5

Minnesota 2

Missouri 6

Nebraska 1

Ohio 99

Oklahoma 9

Texas 5

West Virginia 1

Unknown 4

Grand Total 155

Table 6. Summary of swine jackpot exhibitor perceptions and opinions of the recommendations put forth in the Measures to Minimize Influenza Transmission at Swine Exhibitions document.

Survey Question Yes/Total (%) No/Total (%) Clean and disinfect all tack, feeders, waterers, and show supplies between shows. I think this is a good recommendation 137/155 (88.4) 3/155 (1.9) I can implement this recommendation 125/155 (80.6) 9/155 (5.8) I disinfect all equipment between shows 74/155 (47.7) 70/155 (45.2)

Wash your hands with soap and water when you leave the barn. I think this is a good recommendation 135/155 (87.1) 5/155 (3.2) I can implement this recommendation 124/155 (80) 11/155 (7.1) I wash my hands after I have contact with pigs 106/155 (92.3) 37/155 (23.9)

No food or drink in animal areas. I think this is a good recommendation 91/155 (58.7) 45/155 (29) I can implement this recommendation 89/155 (57.4) 45/155 (29) I eat and/or drink in animal areas 115/155 (74.2) 30/155 (19.4)

Allow at least 7 days of “down time” (i.e. on-farm quarantine) after returning from a previous show before showing a pig or pen-mates, to reduce the risk of spreading influenza. I think a 7 day down time is a good recommendation 110/155 (71) 26/155 (19.1) I can implement a 7 day downtime 83/155 (53.5) 45/155 (29) My pigs are at home for at least 7 days in between shows 76/155 (49) 55/155 (35.5) I think it is a good day to isolate pigs returning home 112/155 (72.3) 20/155 (12.9) I can implement isolation for pigs returning home 90/155 (58.1) 40/155 (25.8) I do isolate pigs for at least 7 days when they return home 69/155 (44.5) 68/155 (43.9)

Discuss the use of swine influenza vaccines with a veterinarian and check the show rules for any requirements. I think this is a good recommendation 130/155 (83.9) 7/155 (4.5) I can implement this recommendation 121/155 (78.1) 11/155 (7.1) My pig (s) were vaccinated for influenza 111/155 (71.6) 22/155 (14.2) I have/will attend a show that requires influenza vaccination for pigs 94/155 (60.6) 29/155 (18.7)

Consult a veterinarian to help outline and implement applicable biosecurity and swine health practices at home. I think this is a good recommendation 133/155 (85.8) 5/155 (3.2) I can implement this recommendation 117/155 (75.5) 10/155 (6.5)

A veterinarian has visited my farm in the last 12 months 127/155 (81.9) 16/155 (10.3) 77

Continued from page 77

Sick pigs and sick people need to stay home so they do not risk infecting other pigs or people. I think this is a good recommendation 139/155 (89.7) 3/155 (1.9)

I can implement this recommendation 127/155 (81.9) 11/155 (7.1) I have taken a sick pigs to a show 29/155 (18.7) 101/155 (65.2) I have gone to a show when I‟ve been sick myself 52/155 (33.5) 79/155 (51)

Avoid sharing tack with other exhibitors, but if you must, clean and disinfect in-between uses. I think this is a good recommendation 123/155 (79.4) 18/155 (11.6) I can implement this recommendation 110/155 (71) 22/155 (14.2) I have shared tack at shows 88/155 (56.8) 43/155 (27.7) I disinfect shared tack 71/155 (45.8) 62/155 (40) No sleeping in animal areas. I think this is a good recommendation 103/155 (66.5) 35/155 (22.6) I can implement this recommendation 87/155 (56.1) 44/155 (33.6) I sleep in animal areas 71/155 (45.8) 64/155 (41.3) Report sick pigs to exhibition organizers I think this is a good recommendation 129/155 (83.2) 16/155 (10.3) I can implement this recommendation 109/155 (70.3) 20/155 (12.9) I have reported sick pigs to show organizers 56/155 (36.1) 74/155 (47.7)

Become familiar with the clinical signs of influenza and other illnesses in pigs. I think this is a good recommendation 136/155 (87.7) 1/155 (0.6) I can implement this recommendation 123/155 (79.4) 8/155 (5.2) I can recognize influenza in pigs 100/155 (64.5) 40/155 (25.8)

Discussion

Understanding the opinions and perceptions of swine exhibitors toward recommendations to mitigate disease is essential in directing further mitigation. Swine jackpot participants and their parents were the target population for this study because they generally were more heavily involved in the show swine industry. Individuals show

pigs at the county fair level, likely have very few pigs and attend only 1-2 shows per year however the families included in this study reported attending an average of 11 shows per year, with a range of 2 to 37 shows (Bliss, 2017). This increased level of show activity allows more opportunity for these individuals to adopt mitigation strategies recommended by animal and public health officials. It also increases their risk for exposure to zoonotic disease, potentially increasing their favoritism toward mitigation.

Thus, the results found in this study may be skewed toward being a more positive view of the recommendations, as compared to individuals who only compete at local fairs.

Besides targeting this population based on the number of shows they attend, swine jackpot participants were also targeted because they are considered experts at the local level and their advice is sought after by local show pig enthusiasts. If the experts consider the recommendations favorable and adopt the practices, they are more likely to encourage local level showman to do the same. This trickle down approach to knowledge dissemination saves time and resources by spreading the information rapidly across large geographic areas. Individuals who show at the local level may be more willing to adopt practices that reduce disease transmission if they are recommended by other swine producers rather than regulatory or university personnel.

Variant influenza A virus cases have not been reported in swine jackpot participants, as they have been reported in county fair swine exhibitors (Schicker, 2016).

This could be attributed to many factors including; increased biosecurity, increased knowledge, shortened length of show exposure, or differences in the viruses circulating within the swine populations. It has been shown in a fair setting, that the prevalence of

swine shedding IAV is <30% at 72 hours post arrival whereas IAV prevalence can be over 90% by the seventh day of the fair (Bowman, unpublished data). Because jackpot shows typically last 1 -3 days, the prevalence of IAV in the pigs stays relatively low during the show, thus decreasing the exposure jackpot participants may have to IAV.

However, these individuals are also more likely to be raising swine full time, rather than purchasing only a few head to show at a local fair, and therefore may have exposures during animal husbandry away from show atmospheres. In addition, the strains of IAV circulating among swine at jackpot shows is genetically nearly identical to virus strains circulating among fair pigs, therefore the difference in variant cases is likely not due to viral strain (Bowman, unpublished data). The differences seen are then likely due to increased biosecurity or knowledge of the risks associated with zoonotic diseases.

The “Measures to Minimize…” document has been disseminated across the country through extension and health officials; however the breadth of impact it has made is currently unknown. Survey results indicate that 19 – 92% of respondents have already implemented the respective recommendations included on the questionnaire. Whether they implemented these practices because they saw the specific recommendation in the

“Measures…” document or because they gained knowledge through some other venue is still unknown, however it is important to document the practices currently being followed by the show swine industry. This knowledge can be used to lead further investigation into behavior changes that could prevent animal – human transmission of zoonotic diseases.

Chapter 7: Recommendations, Future Research, and Conclusions

Recommendations

Scenario-based training sessions, Becoming a Swientist programming, zoonotic disease skill-a-thon stations, and disseminating recommendations through the Swine

Resource Handbook and Measures to Minimize… documents were all effective methods to educate youth in the risks and prevention of zoonotic diseases. These methods should be considered for implementation to help reduce the threat of zoonotic influenza viruses.

All of the materials that have been created have been shared on the Basecamp site used by CSTE and CDC for the “Educating Youth in Agriculture” program, which has provided funding for this project. In addition, the materials are being made available to the public for use by any interested educators.

Future Research

Due to the ecology of influenza A viruses and their predilection to mutate, each transmission across the animal-human species barrier could result in the next pandemic influenza A virus strain. Influenza A virus pandemics have historically had catastrophic consequences on human health and economies; therefore, any mitigation that can be done to minimize the threat of an emergent virus can potentially save countless animal and human lives.

Agricultural exhibitions are imperative to attracting the interest of and training the next generation of agriculturalist, with whom the world relies upon for safe and secure

food sources. However, contracting influenza A virus from swine at agricultural exhibitions is not only detrimental to the health of these children, but could also deter them from pursuing a career in agriculture. Understanding exhibitors‟ perception of the recommendations and barriers to adoption is critical because exhibitor compliance with proposed mitigation strategies is key in decreasing influenza A virus burden in swine, thus reducing the risk of influenza A virus transmission from pigs to people.

Understanding the economics of the exhibition swine industry and the financial impact influenza A virus outbreaks have on society and the exhibition swine industry may give insight into the justification for the adoption or opposition of mitigation recommendations.

The following research questions should be addressed to guide the next steps in preventing transmission of zoonotic disease between pigs and people at agricultural exhibitions: 1) What is the total value of the exhibition swine industry in the United

States? 2) What are the associated costs of influenza A virus outbreaks at swine exhibitions at the local, state, and national levels? 3) What barriers are responsible for the lack of adoption of disease mitigation strategies among swine exhibitors? 4) How do swine exhibitors measure risk over reward when choosing which recommended healthy habits to employee in their routine?

Not only should the above mentioned research questions be addressed, but the

Measures to Minimize… document should be altered to be more appropriate for youth audiences. It contains much more information than what is needed for youth exhibitors

and is formatted in an unattractive manner. In addition, the new document should be disseminated through methods that reach youth to increase the impact of the document.

Conclusions

Educating youth regarding the risk of zoonotic disease is an important animal and public health concern as nearly three out five new human illnesses are zoonotic (CDC,

2017). In addition, disease prevention was determined to be the life skill least represented in 4-H youth development programming, making this an important addition to youth agricultural programs (Maass, S, 2006). Justification for increased diligence in this area is highlighted by the continual cases of H3N2v reported in youth swine exhibitors associated with agricultural fairs (Schicker, 2016). Management practices common in the exhibition swine industry facilitate the rapid intra- and inter-species transmission of influenza A virus. However, several mitigation strategies that require alterations management practices have been developed and validated to protect animal and public health. Leading transitions is impossible without evidence to support the proposed behavioral changes; therefore data collected from the studies conducted at The Ohio State

University have been used to develop a multi-faceted educational program to educate youth on the risk associated with zoonotic disease. Building a repertoire of mitigation strategies based on scientific evidence is a key component to the development of sustainable educational programming because it provides a means by which exhibitors can be a part of the solution.

Animal and public health experts have worked alongside extension educators to create and implement engaging programming that is effective at educating youth regarding the transmission of zoonotic diseases, and the effects of these diseases on animal and public health. Justification for increased diligence in this area is highlighted by the continual cases of H3N2v reported in youth swine exhibitors associated with agricultural fairs.

In the present study, researchers were specifically concerned with developing materials considered to be a tool in Engerstrom‟s conceptual framework, based on the

(Jonassen, 1999).

The Activity Theory was supported in this current study with measurable perceived gain of knowledge by participants after completing hands-on activities in which they were actively engaged. In addition, several healthy habit recommendations have been adopted by a majority of jackpot show exhibitors, indicating some objects were being achieved.

Relying on a trickle-down effect for knowledge dissemination may not be effective for preventing disease transmission between youth and animals, therefore efforts must be focused toward leading transition directly within this group. Several suggestions presented in “Managing Transitions” (Bridges, 1991) have be used to lead

youth to adopt healthy habits associated with disease prevention. The suggestions implemented in this study include rewards/compensation, use of a symbolic logo, and comprehensive training plans (Bridges, 1991). The majority of youth exhibiting swine were enrolled in 4-H and FFA programs and show at local agricultural fairs, however there was a select population of these youth who show on a regular basis throughout the year in jackpot shows, as part of the Swine Show Circuit. Starting the transition with these youth can be beneficial as they are exposed to swine and their diseases on a regular basis and also because they are often leaders of the swine departments at the local level because of their vast experience.

Developing an incentivized educational program to share knowledge with these youth could be a driver in transitions leading to behavior changes. First, hands on training took place to initiate the Ending, Losing, Letting Go phase. Next, youth submitted photo documentation, selfies, to a specific online portal to document the practice of healthy habits for which they earned points toward winning prizes. This represents the neutral zone, as youth started to practice new behaviors, but are unlikely to fully expect the changed behaviors at this juncture. Upon completion of face-face and online training modules, and documenting healthy habits for the duration of the show season, prizes were awarded and youth were deemed “Swientist.”

Although mitigation strategies have been developed and information is being disseminated, youth swine exhibitors, their families, and livestock show organizers have been slow to adopt healthy habits aiming to reduce zoonotic disease transmission, even after receiving education about the potential outcomes of influenza A virus infection.

Understanding the economic and social issues molding perceptions of risk, leading to a lack of behavior change is imperative to guide future educational outreach.

References

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Capua Ilaria, Olga Munoz. Emergence of influenza viruses with zoonotic potential: Open issues which need to be addressed. A review. Veterinary Microbiology, 2013; 165 p 7-12. Choi, T. R., Sung, Y., Lee, J. A., & Choi, S. M. (2017). Get behind my selfies: the Big Five traits and social networking behaviors through selfies. Personality and Individual Differences, 109, 98-101. Clark, R., (2009). Accelerating expertise with scenario based learning. Learning Blueprint. Merrifield, VA: American Society for Teaching and Development. Cole, Anna Gahl. (2007) Expanding the field: Revisiting environmental education principles through multidisciplinary frameworks. The Journal of Environmental Education; 38 (2) p 35-44. Cole, D.J. (1994, February) Bridging traditional and authentic assessment. Paper presented at the Annual meeting of the American Association of Colleges for Teacher Education, Chicago. (ERIC Document Reproduction Service No. ED37480). Corzo Cesar A., Marie Culhane, Scott Dee, Robert B. Morrison, Montserrat Torremorell. Airborne Detection and Quatification of Swine in Influenza A Virus Air Samples Collected Inside, Outside, and Downwind from Swine Barns. PLoS ONE. 2013;8(8): 1 – 7. Crisci Elisa, Tufaria Mussa, Lorenzo Fraile, Maria Montoya. Review: influenza virus in pigs. Molecular Immunology, 2013; 55 p 200-211. Darling-Hammond, L, & Snyder J. (1999(. Authentic assessment of teaching in context. Teaching and Teacher Evaluation, 16, 523-545. Epperson, S., Jhung, M., Richards, S., Quinlisk, P., Ball, L., Moll, M., . . . Finelli, L. (2013). Human infections with influenza A(H3N2) variant virus in the United States, 2011-2012. Clin Infect Dis, 57 Suppl 1, S4-S11. doi:10.1093/cid/cit272. Ghisi Gabriela Lima de Malo, Sherry L. Grace, Scott Thomas, Paul Oh. Behavior determinants amoung cardiac rehabilitation patients receiving educational interventions; An application of the health action process approach. Patient Educ Couns. 015; doi: 10.1016/j.pec.2015.01.006. Influenza. (n.d.). Retrieved November 20, 2017, from https://www.merriam-webster.com/dictionary/influenza. Ito, T., Couceiro, J. N., Kelm, S., Baum, L. G., Krauss, S., Castrucci, M. R., . . . Kawaoka, Y. (1998). Molecular basis for the generation in pigs of influenza A viruses with pandemic potential. J Virol, 72(9), 7367-7373. Karasin AI, Carman S, Olsen CW. Identification of human H1N2 and human-swine reassortant H1N2 and H1N1 influenza A viruses among pigs in Ontario, Canada (2003 to 2005). Journal of clinical microbiology. 2006;44(3):1123-6. Kramer, Florian. Emerging influenza viruses and the prospect of a universal influenza vaccine. Biotechnology Journal. 2015; 10 p 1-12 doi: 10.1002/biot.201400393 Hoa, L.N.M., J.E. Bryant, M. Choisy, L.A. Nguyent, N.T. Bao, N.H. trang, N.T,K. Chuc, T.K. Toan, T. Saito, N. Takemae, P. Horby, H. Wertheim, A. Fox. Population susceptibility to a variant swine-origin influenza virus A (H3N2) in Vietnam, 2011-2012. Epidemiol. Infect. 2015; p 1-6 Doi:10.1017/S0950268815000187. 88

Leontiev, Aleksei Nikolaevich (1978): Activity, consciousness, and personality (originally published in Russian in 1975). Prentice-Hall. Leontiev, Aleksei Nikolaevich (1981): Problems of the development of the mind (originally published in Russian in 1959). Moscow, Russia, Progress. Jhung, M. A., Epperson, S., Biggerstaff, M., Allen, D., Balish, A., Barnes, N., . . . Finelli, L. (2013). Outbreak of variant influenza A(H3N2) virus in the United States. Clin Infect Dis, 57(12), 1703-1712. doi:10.1093/cid/cit649. Jonassen David H, and Lucia Roher-Murphy. Activity theory as a framework for designing constructivist learning environments. ETR&D 1999; 47:1 p61-79. Karasin, A. I., Carman, S., & Olsen, C. W. (2006). Identification of human H1N2 and human-swine reassortant H1N2 and H1N1 influenza A viruses among pigs in Ontario, Canada (2003 to 2005). J Clin Microbiol, 44(3), 1123-1126. doi:10.1128/JCM.44.3.1123-1126.2006. Ma, W., Kahn, R. E., & Richt, J. A. (2008). The pig as a mixing vessel for influenza viruses: Human and veterinary implications. J Mol Genet Med, 3(1), 158-166. Maass, Sarah E., C. S. W., Joy Jordan, Gerald Culen, Nick Place. (2006). A Comparison of 4-H and Other Youth Development Organizations in the Development of Life Skills. Journal of Extension, 44(5). Miranda-Novales Guadalupe, Lourdes Arriange-Pizano, Cristina Herrera-Castillo, Rodolf Pastelin-Palacios, Nuriban Valero-Pacheco, Marisol Perez-Toledo, Eduardo Ferat-Osorio, Fortino Solorzano-Santos, Guillermo Vazquez-Rosales, Clara Espitia-Pinzon, Irma Zamudio-Lugo, Abigail Meza- Chavez, Paul Klenerman, Armando Isibasi, Constantino Lopez-Macias. Antibody responses to influenza viruses in paediatric patients and their contacts at the onest of the 2009 pandemic in Mexico. The Journal of Infection in Developing Countries. 2015; 9(3): 259-266 doi: 10.3855/jjdc.5052. Murphey David A, Kelly H. Lamonda, Jan K Carney, Paula Duncan. Relationships of a brief measure of youth assets to health-promoting and risk behaviors. Journal of Adoclescent Health. 2004; 34 p 184-191. Myers, K. P., Olsen, C. W., & Gray, G. C. (2007). Cases of swine influenza in humans: a review of the literature. Clin Infect Dis, 44(8), 1084-1088. doi:10.1086/512813Ma W, Kahn RE, Richt JA. (Ma et al., 2008). Journal of molecular and genetic medicine. 2008;3(1):158-66. Nelson Martha I., Amy L. Vincent. Reverse zoonosis of influenza to swine: new perspectives on the human-animal interface. Trends in Microbiology, 2015; 23 (3) p 142-152. Olsen, C. W. (2002). The emergence of novel swine influenza viruses in North America. Virus Res, 85(2), 199-210. Peiris, J. S., Poon, L. L., & Guan, Y. (2012). Public health. Surveillance of animal influenza for pandemic preparedness. Science, 335(6073), 1173-1174. doi:10.1126/science.1219936.

Perkins Daniel F, Sarah Meyer Chilenski, Jonathan R. Olson, Claudia C. Mincemoyer, and Richard Spoth. Knowledge, Attitudes, and commitment concerning evidence- based prevention programs: Differences between family and consumer sciences and 4-H development educators. J. Ext. 2014; 52 (3). Reeves, Liane, Rosan Meyer, Judith Holloway, Carina Venter. The development and implementation of a training package for dietitians on cow‟s milk protein allergy in infants and children based on UK RCPCH competencies for food allergies – a pilot study. Clinical and Translational Allergy. 2015; 5:4 doi 10.1186/s13601- 015-00446-y. Reid, A. H., & Taubenberger, J. K. (2003). The origin of the 1918 pandemic influenza virus: a continuing enigma. J Gen Virol, 84(Pt 9), 2285-2292. Roberts, T.G. A Philosophical Examination of Experiential Learning Theory For Agricultural Educators. Journal of Agricultural Education,2006; 47 (1), 17-29 Roberts, T. Grady, Anna L. Ball. Secondary agricultural science as content and context for teaching. Journal of Agriculture Education. 2009; 50(1) p 81-91. Russell Earl B. Attracting youth to agriculture. Journal of Extension. 1993; 31:4 4FEA2. Rusk, C. P., Egger, T., Machtmes, K., & Richert, B. T. (2002). Junior pork day: A family experience. Journal of Extension. Rusk, C. P., & Machtmes, K. (2002). Teaching youth through 4-H animal science workshops. Journal of Extension, 40(5), 1-3. Saenz, R. A., Hethcote, H. W., & Gray, G. C. (2006). Confined animal feeding operations as amplifiers of influenza. Vector Borne Zoonotic Dis, 6(4), 338-346. doi:10.1089/vbz.2006.6.338. Schicker, R. S., Rossow, J., Eckel, S., Fisher, N., Bidol, S., Tatham, L., . . . Biggerstaff, M. (2016). Outbreak of Influenza A(H3N2) Variant Virus Infections Among Persons Attending Agricultural Fairs Housing Infected Swine - Michigan and Ohio, July-August 2016. MMWR Morb Mortal Wkly Rep, 65(42), 1157-1160. doi:10.15585/mmwr.mm6542a1. Skowronski Danuta M, Flavia S. Moser, Naveed Z Janjua, Bahman Davoudi, Krista M English, Dale Purych, Martin Petric, Babk Pourbohloul. Molecular evidence for interspecies transmission of H3N2pM/H3N2v influenza A viruses at an Ohio agricultural fair, July 2012. Emerging Microbes & Infections. 2012;1(10):e33. Smith, N. M., Bresee, J. S., Shay, D. K., Uyeki, T. M., Cox, N. J., & Strikas, R. A. (2006). Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep, 55(RR-10), 1-42. Vincent, A. L., Ma, W., Lager, K. M., Gramer, M. R., Richt, J. A., & Janke, B. H. (2009). Characterization of a newly emerged genetic cluster of H1N1 and H1N2 swine influenza virus in the United States. Virus Genes, 39(2), 176-185. doi:10.1007/s11262-009-0386-6. Washington Charles H, Francis J Tyler, Julia Davis, Douglas R. Shapiro, Adam Richards, Matthew Richard, Thomas J Lee, Taryn L Colton, Louis Berk, Loren Rauch, Eh Kalu Shwe Oo, Richard Hahn, Lawrence M Stock. Trauma training course: innovative teaching models and methods or training health workers in active 90

conflict zones of Eastern Myanmar. International Journal of Emergency Medicine. 2014; 7:46 doi: 10.1186/s12245-014-0046-z. Webby, R. J., Rossow, K., Erickson, G., Sims, Y., & Webster, R. (2004). Multiple lineages of antigenically and genetically diverse influenza A virus co-circulate in the United States swine population. Virus Res, 103(1-2), 67-73. doi:10.1016/j.virusres.2004.02.015. Webster RG. The importance of animal influenza for human disease. Vaccine. 2002;20 Suppl 2:S16-20. What is FFA? Retreived November 20, 2017, from https://www.ffa.org/about/what-is-ffa. Ye Jianqiana , Yifei Xu , Jillian Harris , Hailiang Sun , Andrew S. Bowman , Fred Cunningham , Carol Cardona , Kyoungjin J.Yoon, Richard D.Slemons , Xiu- FengWan. Mutation from arginine to lysine at the position 189 of hemagglutinin contributes to the antigenic drift in H3N2 swine influenza viruses. Virology. 2013; 4 (46) p 225-229. Zoonosis. (n.d.). Retrieved November 20, 2017, from https://www.merriam- webster.com/dictionary/zoonosis.

Appendix A: Pre and Post-test

Influenza A virus at county fairs pre-test

Participant Number:

Age:

Years showing pigs:

For each item identified below, circle the number to the right that best fits your judgment of its quality. Use the rating scale to select the quality number.

Scale

Y Survey Item N Maybe e o s

1. I have heard of influenza A viruses 1 2 3 4 5

2. I know pigs can get influenza A viruses 1 2 3 4 5

3. I know what the “H” and “N” mean in the name of 1 2 3 4 5 influenza A viruses

4. I know how influenza A viruses spread between animals 1 2 3 4 5

5. I know how influenza A viruses spread between animals 1 2 3 4 5 and people

6. I know what to do before the fair if my pig seems sick 1 2 3 4 5

7. I know what to do at the fair if my pig seems sick 1 2 3 4 5

8. I know what to do after the fair if my pig comes home 1 2 3 4 5 with me

9. I get a flu vaccination each year 1 2 3 4 5

10. My pigs have been vaccinated for influenza A viruses 1 2 3 4 5

11. I have more than one pig at home 1 2 3 4 5

12. I have a veterinarian that I can call if my pig is sick 1 2 3 4 5

13. I have animals other than pigs at home 1 2 3 4 5

14. I know how to take a pigs temperature 1 2 3 4 5

15. I know the clinical signs of influenza in pigs 1 2 3 4 5

16. I am confident in my ability to tell when a pig is sick 1 2 3 4 5

17. I have had influenza infections before (the flu) 1 2 3 4 5

18. I know who to talk to if I think I have influenza 1 2 3 4 5

19. I know what factors make it more risky for humans to visit 1 2 3 4 5 pig barns

20. I know what the term bio-security means 1 2 3 4 5

Influenza A Virus at county fairs Post-Test

Participant Number:

Age:

Years showing pigs:

For each item identified below, circle the number to the right that best fits your judgment of its quality. Use the rating scale to select the quality number.

Scale

Y N Survey Item Maybe e o s

21. I have heard of influenza A viruses 1 2 3 4 5

22. I know pigs can get influenza A viruses 1 2 3 4 5

23. I know what the “H” and “N” mean in the name of 1 2 3 4 5 influenza A viruses

24. I know how influenza A viruses spread between animals 1 2 3 4 5

25. I know how influenza A viruses spread between animals 1 2 3 4 5 and people

26. I know what to do before the fair if my pig seems sick 1 2 3 4 5

27. I know what to do at the fair if my pig seems sick 1 2 3 4 5

28. I know what to do after the fair if my pig comes home 1 2 3 4 5 with me

29. I get a flu vaccination each year 1 2 3 4 5

30. My pigs have been vaccinated for influenza A viruses 1 2 3 4 5

31. I have more than one pig at home 1 2 3 4 5

32. I have a veterinarian that I can call if my pig is sick 1 2 3 4 5

33. I have animals other than pigs at home 1 2 3 4 5

34. I know how to take a pigs temperature 1 2 3 4 5

35. I know the clinical signs of influenza in pigs 1 2 3 4 5

36. I am confident in my ability to tell when a pig is sick 1 2 3 4 5

37. I know more about influenza now than before the lesson 1 2 3 4 5

38. I know who to talk to if I think I have influenza 1 2 3 4 5

39. I know what factors make it more risky for humans to visit 1 2 3 4 5 pig barns

40. I know what the term bio-security means 1 2 3 4 5

Appendix B: Swine Zoonotic Disease Risks and Prevention chapter

100

101

102

103

Appendix C: Minimizing influenza in show pigs survey

104

105

106

Appendix D: Scenario Based Training Lesson Plan

107

Scenario Based Training Lesson Plan

Interest Approach

Students will be seated in small groups around tables. A stuffed pig that has been previously coated with glitter will be in the middle of each table. Learners will be asked to introduce themselves including their names, where they are from, how many years they have been in 4-H, and how long they have been raising pigs. Whichever student is speaking will hold the pig, then pass it to whoever at the table they choose. After the introductions are complete, the facilitator will ask the students to look at their hands to see if they notice anything out of the ordinary. The fact that glitter ends up everywhere will be used to introduce the method by which influenza viruses spread.

Lesson Outline

Upon completion of the above mentioned interest approach the following events will occur:

1. Pre-test evaluation (5 minutes)

2. Power point lecture – (20 minutes)

a. Objectives for session

b. What is influenza?

c. What is swine influenza (SIV)?

d. How to know if your pig is sick

e. History of SIV at agricultural fairs and exhibition

108

f. Snout wipe video: https://www.youtube.com/watch?v=UhnGak-

SrvI

g. Best management practices on the farm

h. What to do if your pig gets sick before, during, or after the show

i. What to do if you gets sick before, during, or after the show

3. Group Scenario Activity (30 minutes)

Participants will work together in groups of 3-4 to complete the scenario handout. The groups will discuss the questions amongst themselves to formulate their ideas regarding the following questions:

1. How do you think pigs may become infected with influenza A viruses? 2. What do you think a sick pig looks like? Draw a picture of a healthy pig and a picture of a sick pig. What are the symptoms of a sick pig? 3. Should sick pigs be allowed to show at the fair? Why or why not? 4. What are some ways you think you could prevent the spread of influenza A viruses among pigs at the fair? 5. What should you do if your pig gets sick before the fair? During the fair? 6. What should do with pigs that get taken home from the fair?

4. Group reporting and wrap-up (30 minutes)

 All small group discussions will cease and as a larger group each

question will be addressed. Individual groups will first report their ideas

on the topic and then facilitators will offer suggestions

 Summary of take home messages 109

 Post-test administration (see appendix)

 Questions and Answers

 Pass out handouts

Handouts

 “Measures to Minimize Influenza Transmission at Swine Exhibition, 2014”

 “Biosecurity Considerations”

 “Influenza H3N2v: Key Facts for People Exhibiting Pigs at Fairs”

 “ A Champions Guide to Youth Swine Exhibition

110

Appendix E: Swientist logo

111

112

Appendix F: Measures to Minimize Influenza Transmission at Swine Exhibitions

113

National Assembly of State Animal Health Officials

(NASAHO) National Association of State Public Health

Veterinarians (NASPHV)

Measures to Minimize Influenza Transmission at Swine

Exhibitions, 2018

Livestock shows are an important learning opportunity for thousands of 4-H and FFA youth across the United States. For these youth, exhibiting at their county or state fair represents the culmination of many months of work dedicated to the care and training of their animals. Agricultural exhibitions also provide meaningful opportunities for the public to learn about animal agriculture, observe animal behavior, and experience what it might be like to live on a farm. More than 150 million people visit agricultural fairs each year in North America.

Influenza can spread whenever animals or people congregate, and agricultural fairs are no exception. While rare, influenza A viruses can spread from people to pigs and from pigs to people. When a person is infected with a swine-origin influenza A virus, it is termed a variant virus infection, and denoted with a “v” after the subtype (e.g. H3N2v).1 (Note that the same virus when found in pigs does not carry the “v” denotation.) In the past 7 years, human cases of influenza A H1N1v, H1N2v, and particularly, H3N2v have been associated with exposure to swine at exhibitions. Between 2011 and 2017, 426 human H3N2v cases were reported from 18 states.2 The largest outbreak occurred in 2012 when a total of 309 human cases of H3N2v flu were identified, including 16 hospitalizations and one death.3 In 2017, a total of 67 variant virus infections (62 H3N2v, 1 H1N1v, and 4 H1N2v) were identified from 10 states (CDC, personal communication). The majority of all of these variant cases were exhibitors and others who reported close contact with pigs at agricultural fairs prior to their onset of illness.

The Swine Exhibitions Zoonotic Influenza Working Group gathered in December 2012 to develop a set of measures to minimize influenza virus transmission between swine, and bidirectionally between people and swine, at swine exhibitions. The group reviewed the document again in 2014 and 2015, and made minor updates. In 2016, because of important new data regarding the dynamics of influenza transmission between swine at exhibitions,4-7 the measures for prevention were strengthened and augmented. In particular, a 2015 study by Bowman et al. found that at swine shows, the prevalence of influenza A-positive pigs increases substantially at 72 hours.8 This finding further supported the recommendation that exhibition swine should be kept on the exhibition grounds no longer than 72 hours. With this 114

2018 edition, there is the addition of an easily accessible checklist for exhibition organizers and youth organization leaders.

The suggested measures in this document are organized to address activities before, during, and after swine exhibitions. It may not be possible to prevent all transmission of influenza viruses at swine exhibitions. The measures described here are offered for careful consideration depending on the needs of the specific exhibition and can be implemented in part or in total. They are not intended to supersede local, state, or federal regulations. These measures were formulated based on current evidence and the collective knowledge of the Swine Exhibitions Zoonotic Influenza Working Group. It is expected that this document will be updated as additional information becomes available.

A reminder that it is recommended by the Centers for Disease Control and Prevention (CDC) that everyone 6 months of age or older be vaccinated annually against seasonal influenza.9 This is particularly important for people who are involved with swine shows because swine are susceptible to human seasonal flu viruses and people can get swine-origin influenza viruses. Vaccination helps to protect people and pigs. In addition, some people are more likely to experience complications from influenza that can result in hospitalization and sometimes death. People at high risk for developing severe complications include children younger than 5 years of age, people 65 years of age and older, pregnant women, and people with certain long-term health conditions (such as asthma, diabetes, heart disease, chronic respiratory disease, weakened immune systems, and neurological or neurodevelopmental conditions.)10 People in these high-risk groups should be made aware of their increased risk through signage and other educational efforts, and they should avoid contact with infected swine.

Measures to Consider BEFORE the Exhibition

For Exhibition Organizers and Youth Organization Leaders

 Collect sufficient contact information (i.e. email addresses and cell phone numbers) from all exhibitors to be able to rapidly communicate procedural changes, requests for information, or incidents associated with the exhibition.  Collect contact information for state animal health officials and local or state public health officials to ensure they can be reached if they are needed during an event.  Maintain records of individual swine identification and source farms to enhance the speed and accuracy of an animal disease investigation associated with the exhibition.  Establish a relationship with a veterinarian who will be present or on call for the duration of the exhibition. The veterinarian will be responsible for monitoring the 115

animals for clinical signs, evaluating sick animals and taking steps to ensure that ill swine are removed from the exhibition area and isolated. o The veterinarian should be equipped to test pigs with signs of influenza  Obtain or create informational signage for the entrance of the exhibition area that includes 11 the following messages: o All animals can carry germs that make people sick o Some people are more likely to get sick: babies and children under 5 years of age, pregnant women, older adults, and people with weakened immune systems or chronic illnesses o Wash your hands with soap and water right after visiting the animals o No food, drinks, baby bottles, pacifiers, toys or strollers in animal areas o Make sure kids don’t put their fingers or other things in their mouths  Ensure that handwashing stations with running water, soap and paper towels will be available near the exit of the exhibition area.  Obtain signs for the exits that instruct visitors to wash their hands when leaving the animal area.  Locate food service areas away from animal barns.  Host non-animal-related activities (i.e. dances, pizza parties, etc.) in locations other than animal barns.  Limit the time pigs are congregated, co-mingled, and held at an exhibition: o Exhibition swine should be kept on the exhibition grounds no longer than 72 hours o Discourage “holdover pigs” that are held on the exhibition grounds and exhibited in additional shows o Release pigs from the exhibition grounds as soon as possible following their respective show(s) o If offering both terminal pig and breeding swine shows, schedule the terminal show after the breeding swine show or schedule a break between shows. Use this break to clean and disinfect the facility o Locate longer-term swine exhibits (i.e. big boars, birthing center animals, display exhibits of pigs) away from areas where competition swine are housed  Identify a temporary isolation area for sick pigs on or near the exhibition or fairgrounds. o Establish a protocol to immediately remove sick swine from the exhibition area  Gather basic supplies and personal protective equipment such as disinfectants, thermometers, gloves, masks, goggles, and disposable boots.  Clean and disinfect gates, chutes, sort panels, and any equipment that will be used during weighing and identification procedures. o Use approved disinfectants that are safe for human and animal contact: https://www.epa.gov/sites/production/files/2018- 01/documents/2018.10.01.listm_.pdf o Establish a protocol and prepare for cleaning and disinfection of chutes and equipment between groups of animals on entry day and during the fair: http://www.cfsph.iastate.edu/Disinfection/index.php

116

For Exhibitors

 Consult a veterinarian to help outline and implement applicable biosecurity and swine health practices at home.  Discuss the use of swine influenza vaccines with a veterinarian and check the exhibition rules for any requirements. Vaccines are available commercially and may be used prior to an exhibition as long as slaughter withdrawal times are observed as appropriate. Swine vaccinated for influenza may be less likely to become ill, and if they become sick, they may be contagious for a shorter time-period.  Become familiar with the clinical signs of influenza and other illnesses in pigs (off feed, lethargic, fever, nasal discharge, and cough).  Seek veterinary assistance if a pig becomes sick.  Understand the risks to both humans and animals of taking a sick pig to a show. Sick pigs need to stay home so they do not risk infecting other pigs or people.  Likewise, sick people can be infectious to pigs and other people. People with influenza- like illness should stay away from pigs and other people until they are fever-free for at 12 least 24 hours without the use of fever-reducing medication.  Ask the exhibition organizer about any specific actions that may be required if a pig becomes sick at the show.  Clean and disinfect all tack, feeders, waterers, and show supplies before bringing them to the fair.  Allow at least 7 days of “down time” (i.e. on-farm quarantine) after returning from a previous exhibition before showing a pig or pen-mates, to reduce the risk of spreading influenza.

For State Animal and Public Health Officials

 Each state should establish and maintain a communications network that includes exhibition organizers and managers, youth organization leaders, state animal health officials, state and local public health officials, show veterinarians, Cooperative Extension Service educators, vocational agriculture instructors and other stakeholders.  State animal health officials should develop a testing protocol for swine that have clinical signs consistent with influenza. o Plan to distribute any test results to the appropriate animal health and public health agencies  State or local public health officials should coordinate with exhibition organizers and youth agriculture organizations to develop a testing protocol for exhibitors who develop influenza-like-illness during or after the exhibition. o Plan to distribute any test results to the appropriate animal health and public health agencies

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Measures to Consider DURING the Exhibition

For Exhibition Organizers and Youth Organization Leaders

 Track arrival, stalling, and release of pigs.  Host a meeting with exhibitors and their family members at the start of the exhibition to: o Review exhibition regulations o Provide contact information for the designated exhibition veterinarian o Review animal disease control measures to be utilized during the exhibition, including the daily monitoring of the animals during the show o Provide instructions on how to monitor and report sick pigs o Explain any specific actions that may be required if a pig becomes sick at the show o Provide instructions on actions to take if exhibitors or family members develop influenza-like illness o Explain and encourage good hygiene practices for people and animals such as washing hands, not eating in the barn, not sharing equipment, maintaining clean animals and pens o Discourage sleeping in the animal areas  Clean and disinfect gates, chutes, sort panels, and any equipment used during weighing and identification procedures frequently, ideally between each group of pigs. o For information on how to use disinfectants: http://www.cfsph.iastate.edu/Disinfection/index.php o For disinfectants that are approved and safe for human and animal contact: https://www.epa.gov/sites/production/files/2018- 01/documents/2018.10.01.listm_.pdf o Keep the environment as dry as possible to avoid animal injury  Monitor the weather forecast. o For extreme heat conditions consider altering arrival and release schedules to minimize heat exposure

For Exhibitors

 Avoid sharing tack with other exhibitors, but if you must, clean and disinfect in- between uses.  Observe swine regularly for signs of influenza-like illness (e.g. off feed, lethargic, fever, nasal discharge, and cough). 118

o Report any influenza-like illness to the designated show veterinarian or the appropriate exhibition staff so the pig can be evaluated right away o Swine that are ill should be removed from the exhibition immediately or moved to a temporary isolation area on or near the exhibition or fairgrounds  Use precautions when caring for sick pigs to minimize the opportunity for disease transmission to other swine or people; for example: o Limit the number of people caring for sick pigs o Use personal protective equipment o Wash hands thoroughly with soap and water after working with sick pigs o Avoid moving bedding and other materials from sick pig areas into areas where healthy pigs are kept o Clean and disinfect equipment

Measures to Consider if there is an Outbreak of Influenza in Pigs or People

For Exhibition Organizers and Youth Organization Leaders

 Notify and work with the show veterinarian.  Notify animal health officials- the State Veterinarian.  Notify local or state public health officials- the State Public Health Veterinarian or Zoonotic Disease Epidemiologist.  Implement a biosecurity protocol. o Limit access to pigs and the barn area, especially to people at high risk. Additional signage should be posted warning people about the occurrence of influenza, including information about increased risk of serious illness for persons in high-risk groups o Use personal protective equipment in the barn o Work with animal health and public health officials to facilitate testing of sick pigs and sick people o People with influenza-like-illness should be advised to leave the exhibition and seek medical care. Public health should be notified so that special testing for variant influenza infection can be facilitated with the person’s healthcare provider o Enhance cleaning and disinfection protocols o Isolate sick animals o Sick pigs designated for marketing should remain in place until the animals have recovered  Implement communication channels. o Identify an official spokesperson for the media

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o Identify someone to facilitate communications with animal and public health authorities, the show/fair managers, and others

For State Animal and Public Health Officials

 Public health and animal health officials should work together to investigate the source of illness and take appropriate actions to prevent transmission.  Communications with media and the public should be done together and collaboratively.  Public health officials should facilitate human testing for influenza, and attempt to identify additional human cases.  State animal health officials should facilitate testing of sick animals and control animal movement to and from the facility.  After the outbreak, a meeting should be held including animal health, public health, exhibition organizers, and youth organization leaders to discuss challenges and lessons learned.

Measures to Consider AFTER the Exhibition

For Exhibition Organizers and Youth Organization Leaders

 Clean and disinfect the swine exhibition areas, including chutes and equipment.  Hold a debrief meeting to discuss what went well and improvements for next year.

For Exhibitors

 Isolate and observe animals daily for illness after returning home and before allowing contact with other animals. o The isolation/observation period for clinical signs of influenza should be no fewer than 7 days o Clean and disinfect tack, waterers, feeders, show equipment, clothing, shoes, and vehicles/trailers that were at the exhibition o Consult a veterinarian if pigs become ill  Consult a health care provider and your state or local public health department if exhibitors or family members develop influenza-like illness. o Inform the health care provider of exposure to swine o Persons with influenza-like-illness should be tested for influenza virus with guidance from public health. Special testing is required to identify variant influenza infections o Ill people should avoid contact with swine and stay away from other people until they are fever-free for at least 24 hours without the use of fever-reducing medications 120

References

1. World Health Organization webpage: Standardization of terminology for the influenza virus variants infecting humans: Update (2014). Retrieved January 22, 2018, from http://www.who.int/influenza/gisrs_laboratory/terminology_variant/en/ 2. Centers for Disease Control and Prevention webpage: Case Count: Detected U.S. Human Infections with H3N2v by State since August 2011 (2017). Retrieved January 22, 2018 from: http://www.cdc.gov/flu/swineflu/h3n2v-case-count.htm 3. Jhung MA et al. “Outbreak of Variant Influenza A(H3N2) Virus in the United States.” Clinical Infectious Diseases (2013) 57: (12) 1703-1712 4. Bowman, Andrew S et al. “Subclinical Influenza Virus A Infections in Pigs Exhibited at Agricultural Fairs, Ohio, USA, 2009–2011.” Emerging Infectious Diseases 18.12 (2012): 1945–1950. PMC. Web. 24 Oct. 2016. 5. Bowman, Andrew S et al. “Swine-to-Human Transmission of Influenza A(H3N2) Virus at Agricultural Fairs, Ohio, USA, 2012.” Emerging Infectious Diseases 20.9 (2014): 1472– 1480. PMC. Web. 24 Oct. 2016. 6. Edwards, Jody L et al. “Utility of Snout Wipe Samples for Influenza A Virus Surveillance in Exhibition Swine Populations.” Influenza and Other Respiratory Viruses 8.5 (2014): 574–579. PMC. Web. 24 Oct. 2016. 7. Bliss, N et al. “Prevalence of Influenza A Virus in Exhibition Swine during Arrival at Agricultural Fairs.” Zoonoses Public Health 63: 477–485. doi:10.1111/zph.12252. 8. Bowman, Andrew S et al. Abstract #o-101, page 73-74 in Proceedings of the Options IX for the Control of Influenza, August 2016, Chicago IL 9. Centers for Disease Control and Prevention webpage: Get Vaccinated (2017). Retrieved January 23, 2018, from https://www.cdc.gov/flu/consumer/vaccinations.htm 10. Centers for Disease Control and Prevention webpage: People at High Risk of Developing Flu–Related Complications (2017). Retrieved January 22, 2018, from: http://www.cdc.gov/flu/about/disease/high_risk.htm 11. National Association of State Public Health Veterinarians website: The Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2017. Retrieved January 23, 2018, from http://nasphv.org/documentsCompendiumAnimals.htm 12. Centers for Disease Control and Prevention webpage: What People Who Raise Pigs Need to Know about Influenza (flu) (2014). Retrieved January 22, 2018, from https://www.cdc.gov/flu/swineflu/people-raise-pigs-flu.htm

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Other Resources

 National Pork Board Website: A Champion's Guide to Youth Swine Exhibition: Biosecurity and Your Pig Project, 2013. Retrieved January 29, 2018. from http://porkcdn.s3.amazonaws.com/sites/all/files/documents/NPB%20A%20Champions%2 0Guide%20to%20Youth%20Swine%20Exhibition.pdf

Working Group Members

Dr. Bret Marsh, Co-chair, National Assembly of State Animal Health Officials Dr. Joni Scheftel, Co-chair, National Association of State Public Health Veterinarians Dr. Jeff Bender, School of Public Health, University of Minnesota Ms. Lenee Blanton, Centers for Disease Control and Prevention Dr. Andrew Bowman, The Ohio State University Dr. Tom Burkgren, American Association of Swine Veterinarians Ms. Marla Calico, International Association of Fairs and Exhibitions Dr. Tony Forshey, National Assembly of State Animal Health Officials Dr. Heather Fowler, National Pork Board Dr. Ann Garvey, National Association of State Public Health Veterinarians Dr. Ellen Kasari, United States Department of Agriculture Dr. Lisa Lauxman, USDA, National Institute of Food and Agriculture, Youth & 4-H Mr. Mike Paul, National Swine Registry Dr. Susan Trock, Centers for Disease Control and Prevention

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