Pandemic influenza preparedness in the WHO African region: are we ready yet?

Use of Sentinel Surveillance Platforms for Monitoring SARS-CoV-2 Activity: Evidence From Analysis of Kenya Influenza Sentinel Surveillance Data

BACKGROUND

Little is known about the cocirculation of influenza and SARS-CoV-2 viruses during the COVID-19 pandemic and the use of respiratory disease sentinel surveillance platforms for monitoring SARS-CoV-2 activity in sub-Saharan Africa.

OBJECTIVE

We aimed to describe influenza and SARS-CoV-2 cocirculation in Kenya and how the SARS-CoV-2 data from influenza sentinel surveillance correlated with that of universal national surveillance.

METHODS

From April 2020 to March 2022, we enrolled 7349 patients with severe acute respiratory illness or influenza-like illness at 8 sentinel influenza surveillance sites in Kenya and collected demographic, clinical, underlying medical condition, vaccination, and exposure information, as well as respiratory specimens, from them. Respiratory specimens were tested for influenza and SARS-CoV-2 by real-time reverse transcription polymerase chain reaction. The universal national-level SARS-CoV-2 data were also obtained from the Kenya Ministry of Health. The universal national-level SARS-CoV-2 data were collected from all health facilities nationally, border entry points, and contact tracing in Kenya. Epidemic curves and Pearson r were used to describe the correlation between SARS-CoV-2 positivity in data from the 8 influenza sentinel sites in Kenya and that of the universal national SARS-CoV-2 surveillance data. A logistic regression model was used to assess the association between influenza and SARS-CoV-2 coinfection with severe clinical illness. We defined severe clinical illness as any of oxygen saturation <90%, in-hospital death, admission to intensive care unit or high dependence unit, mechanical ventilation, or a report of any danger sign (ie, inability to drink or eat, severe vomiting, grunting, stridor, or unconsciousness in children younger than 5 years) among patients with severe acute respiratory illness.

RESULTS

Of the 7349 patients from the influenza sentinel surveillance sites, 76.3% (n=5606) were younger than 5 years. We detected any influenza (A or B) in 8.7% (629/7224), SARS-CoV-2 in 10.7% (768/7199), and coinfection in 0.9% (63/7165) of samples tested. Although the number of samples tested for SARS-CoV-2 from the sentinel surveillance was only 0.2% (60 per week vs 36,000 per week) of the number tested in the universal national surveillance, SARS-CoV-2 positivity in the sentinel surveillance data significantly correlated with that of the universal national surveillance (Pearson r=0.58; P<.001). The adjusted odds ratios (aOR) of clinical severe illness among participants with coinfection were similar to those of patients with influenza only (aOR 0.91, 95% CI 0.47-1.79) and SARS-CoV-2 only (aOR 0.92, 95% CI 0.47-1.82).

CONCLUSIONS

Influenza substantially cocirculated with SARS-CoV-2 in Kenya. We found a significant correlation of SARS-CoV-2 positivity in the data from 8 influenza sentinel surveillance sites with that of the universal national SARS-CoV-2 surveillance data. Our findings indicate that the influenza sentinel surveillance system can be used as a sustainable platform for monitoring respiratory pathogens of pandemic potential or public health importance.

Role of hospital leadership in pandemic preparedness: experience at a tertiary hospital in Kenya during the COVID-19 pandemic

INTRODUCTION

Pandemic preparedness refers to being ready for, responding to and recovering from public health crises, and is integral for health security. Hospital leadership is a critical building block of an effective healthcare system, providing policy, accountability and stewardship in a health crisis.

OBJECTIVES AND METHODS

We aimed to describe the leadership and governance structures put in place at the Aga Khan University Hospital, Nairobi, a private not-for-profit tertiary healthcare facility, following the COVID-19 pandemic. We reviewed over 200 hospital documents archived in the COVID-19 repository including those received from the Kenya Ministry of Health, emails, memos, bulletins, meeting minutes, protocols, brochures and flyers. We evaluated and described pandemic preparedness at the hospital under four main themes: (a) leadership, governance and incident management structures; (b) coordination and partnerships; (c) communication strategies; and (d) framework to resolve ethical dilemmas.

RESULTS

The hospital expeditiously established three emergency governance structures, namely a task force, an operations team and an implementation team, to direct and implement evidence-based preparedness strategies. Leveraging on partners, the hospital ensured that risk analyses and decisions made: (1) were based on evidence and in line with the national and global guidelines, (2) were supported by community leaders and (3) expedite financing for urgent hospital activities. Communication strategies were put in place to ensure harmonised COVID-19 messaging to the hospital staff, patients, visitors and the public to minimise misinformation or disinformation. An ethical framework was also established to build trust and transparency among the hospital leadership, staff and patients.

CONCLUSION

The establishment of a hospital leadership structure is crucial for efficient and effective implementation of pandemic preparedness and response strategies which are evidence based, well resourced and ethical. The role of leadership discussed is applicable to healthcare facilities across low and middle-income countries to develop contextualised pandemic preparedness plans.

Indigenous Village-Based Disaster Communication in COVID-19 Management

Introduction: Communication should always take the role to connect the community to disaster risk reduction actions. Communication aspects that must be mainly prepared are the knowledge of disaster signs, elements involved in disasters, disaster communication media, resources, the sources of basic needs of affected communities, the means of aid distribution, and human resources. Communication activities should always be carried out between the community and various stakeholders to ensure their readiness in the face of possible disaster. This study aimed to determine the Indigenous Village-based disaster communication strategy in Bali Province. Methods: This study used a qualitative descriptive method. The data analysis techniques used were data reduction, data presentation and conclusion drawing at pre-research, during research, and post-research. Data collection was done by observing, interviewing and documenting. Results: The results of this study found that the communication model carried out by Bali Province in handling COVID-19 was by utilizing the role of Indigenous Villages and service villages to communicate with the community. The uniqueness of the Bali Province which still adheres to social, cultural and religious aspects becomes its strength in COVID-19 management

Preparedness to Face the COVID-19 Pandemic in Hospice and Palliative Care Services in the Asia-Pacific Region: A Rapid Online Survey

BACKGROUND

Hospice and palliative care services provision for COVID-19 patients is crucial to improve their life quality. There is limited evidence on COVID-19 preparedness of such services in the Asia-Pacific region.

AIM

To evaluate the preparedness and capacity of hospice and palliative care services in the Asia-Pacific region to respond to the COVID-19 pandemic.

METHOD

An online cross-sectional survey was developed based on methodology guidance. Asia-Pacific Hospice and Palliative Care Network subscribers (n = 1551) and organizational members (n = 185) were emailed. Descriptive analysis was undertaken.

RESULTS

Ninety-seven respondents completed the survey. Around half of services were hospital-based (n = 47, 48%), and public-funded (n = 46, 47%). Half of services reported to have confirmed cases (n = 47, 49%) and the majority of the confirmed cases were patients (n = 28, 61%). Staff perceived moderate risk of being infected by COVID-19 (median: 7/10). > 85% of respondents reported they had up-to-date contact list for staff and patients, one-third revealed challenges to keep record of relatives who visited the services (n = 30, 31%), and of patients visited in communities (n = 29, 30%). Majority of services (60%) obtained adequate resources for infection control except face mask. More than half had no guidance on Do Not Resuscitate orders (n = 59, 66%) or on bereavement care for family members (n = 44, 51%).

CONCLUSION

Recommendations to strengthen the preparedness of palliative care services include: 1) improving the access to face mask; 2) acquiring stress management protocols for staff when unavailable; 3) reinforcing the contact tracing system for relatives and visits in the community and 4) developing guidance on patient and family care during patient's dying trajectory.

The Preparedness of Primary Health Care Network in terms of Emergency Risk Communication: A Study in Iran

OBJECTIVE

Emergency Risk Communication (ERC) is known as 1 of the important components of an effective response to public health emergencies. In this study, we aimed to investigate the preparedness of the Primary Health Care Network (PHCN) of Iran in terms of the ERC.

METHODS

This study was conducted in 136 Primary Health Care Facilities (PHCFs) affilated to Shahrekord University of Medical Sciences, Chaharmahal and Bakhtiari Province, Iran. Data in terms of ERC were collected using a checklist developed by the Center of Disease Control and Prevention (CDC).

RESULTS

The findings of the study revealed that 65.9% of the PHCFs had low preparedness in terms of the ERC, 33.3% had a moderate level and 0.8% had high preparedness in this regard. There was a significant difference between the level of ERC and the history of crisis in the past year, PHCF type, and the education level of the responsible employees in the crisis unit in the PHCF.

CONCLUSIONS

The results showed that the PHCFs studied need to increase their capacity and capability in the field of ERC. Further efforts to provide ERC components may increase the preparedness of PHCN in Iran in terms of the ERC.

A baseline review of the ability of hospitals in Kenya to provide emergency and critical care services for COVID-19 patients

Introduction

As the Coronavirus Disease 2019 (COVID-19) cases in Kenya begin to rise, the number of severe and critical COVID-19 patients has the potential to quickly overload the local healthcare system beyond its capacity to treat people.

Objective

The purpose of this study was to gather information about the ability of hospitals in Kenya to provide emergency and critical care services and to identify priority actions for use by policymakers and other stakeholders as a roadmap toward strengthening the COVID-19 response in the country.

Methods

This was a comprehensive review of the published and grey literature on emergency and critical care services in Kenya published in the last three years through April 2020. Screening of articles was conducted independently by the authors and the final decision for inclusion was made collaboratively. A total of 15 papers and documents were included in the review.

Key recommendations

There is an urgent need to strengthen prehospital emergency care in Kenya by establishing a single toll-free ambulance access number and an integrated public Emergency Medical Services (EMS) system to respond to severe and critical COVID-19 patients in the community and other emergency cases. Functional 24-h emergency centres (ECs) need to be established in all the level 4, 5 and 6 hospitals in the country to ensure these patients receive immediate lifesaving emergency care when they arrive at the hospitals. The ECs should be equipped with pulse oximeters and functioning oxygen systems and have the necessary resources and skills to perform endotracheal intubation to manage COVID-19-induced respiratory distress and hypoxia. Additional intensive care unit (ICU) beds and ventilators are also needed to ensure continuity of care for the critically ill patients seen in the EC. Appropriate practical interventions should be instituted to limit the spread of COVID-19 to healthcare personnel and other patients within the healthcare system. Further research with individual facility levels of assessment around infrastructure and service provision is necessary to more narrowly define areas with significant shortfalls in emergency and critical care services as the number of COVID-19 cases in the country increase.

Health Systems and Services During COVID-19: Lessons and Evidence From Previous Crises: A Rapid Scoping Review to Inform the United Nations Research Roadmap for the COVID-19 Recovery

This rapid scoping review has informed the development of the November 2020 United Nations Research Roadmap for the COVID-19 Recovery, by providing a synthesis of available evidence on the impact of pandemics and epidemics on (1) essential services and (2) health systems preparedness and strengthening. Emerging findings point to existing disparities in health systems and services being further exacerbated, with marginalized populations and low- and middle-income countries burdened disproportionately. More broadly, there is a need to further understand short- and long-term impacts of bypassed essential services, quality assurance of services, the role of primary health care in the frontline, and the need for additional mechanisms for effective vaccine messaging and uptake during epidemics. The review also highlights how trust—of institutions, of science, and between communities and health systems—remains central to a successful pandemic response. Finally, previous crises had repeatedly foreshadowed the inability of health systems to handle upcoming pandemics, yet the reactive nature of policies and practices compounded by lack of resources, infrastructure, and political will have resulted in the current failed response to COVID-19. There is therefore an urgent need for investments in implementation science and for strategies to bridge this persistent research–practice gap.

Six Sigma to distinguish patterns in COVID-19 approaches

Purpose

COVID-19 has changed life as we know. Data are scarce and necessary for making decisions on fighting COVID-19. The purpose of this paper is to apply Six Sigma techniques on the current COVID-19 pandemic to distinguish between special cause and common cause variation. In the DMAIC structure, different approaches applied in three countries are compared.

Design/methodology/approach

For three countries the mortality is compared to the population to distinguish between special cause variation and common cause variation. This variation and the patterns in it are assessed to the countries' different approaches to COVID-19.

Findings

In the DMAIC problem-solving approach, patterns in the data are distinguished. The special cause variation is assessed to the special causes and approaches. The moment on which measures were taken has been essential, as well as policies on testing and distancing.

Research limitations/implications

Cross-national data comparisons are a challenge as countries have different moments on which they register data on their population. Furthermore, different intervals are taken, varying from registering weekly to registering yearly. For the research, three countries with similar data registration and different approaches in fighting COVID-19 were taken.

Originality/value

This is the first study with Master Black Belts from different countries on the application of Six Sigma techniques and the DMAIC from the viewpoint of special cause variation on COVID-19.

What Is the Preparedness and Capacity of Palliative Care Services in Middle-Eastern and North African Countries to Respond to COVID-19? A Rapid Survey

CONTEXT

Evidence from prior public health emergencies demonstrates palliative care's importance to manage symptoms, make advance care plans, and improve end-of-life outcomes.

OBJECTIVE

To evaluate the preparedness and capacity of palliative care services in the Middle-East and North Africa region to respond to the COVID-19 pandemic.

METHODS

A cross-sectional online survey was undertaken, with items addressing the WHO International Health Regulations. Nonprobabilistic sampling was used, and descriptive analyses were conducted.

RESULTS

Responses from 43 services in 12 countries were analyzed. Half of respondents were doctors (53%), and services were predominantly hospital based (84%). All but one services had modified at least one procedure to respond to COVID-19. Do Not Resuscitate policies were modified by a third (30%) and unavailable for a fifth (23%). While handwashing facilities at points of entry were available (98%), a third had concerns over accessing disinfectant products (37%), soap (35%), or running water (33%). The majority had capacity to use technology to provide remote care (86%) and contact lists of patients and staff (93%), though only two-fifths had relatives' details (37%). Respondents reported high staff anxiety about becoming infected themselves (median score 8 on 1-10 scale), but only half of services had a stress management procedure (53%). Three-fifths had plans to support triaging COVID-19 patients (60%) and protocols to share (58%).

CONCLUSION

Participating services have prepared to respond to COVID-19, but their capacity to respond may be limited by lack of staff support and resources. We propose recommendations to improve service preparedness and relieve unnecessary suffering.

Preparedness of African Palliative Care Services to Respond to the COVID-19 Pandemic: A Rapid Assessment

CONTEXT

Palliative care is an essential component of the coronavirus disease 2019 (COVID-19) pandemic response but is overlooked in national and international preparedness plans. The preparedness and capacity of African palliative care services to respond to COVID-19 is unknown.

OBJECTIVES

To evaluate the preparedness and capacity of African palliative care services to respond to the COVID-19 pandemic.

METHODS

We developed, piloted, and conducted a cross-sectional online survey guided by the 2005 International Health Regulations. It was electronically mailed to the 166 African Palliative Care Association's members and partners. Descriptive analyses were conducted.

RESULTS

About 83 participants from 21 countries completed the survey. Most services had at least one procedure for the case management of COVID-19 or another infectious disease (63%). Respondents reported concerns over accessing running water, soap, and disinfectant products (43%, 42%, and 59%, respectively) and security concerns for themselves or their staff (52%). Two in five services (41%) did not have any or make available additional personal protective equipment. Most services (80%) reported having the capacity to use technology instead of face-to-face appointment, and half (52%) reported having palliative care protocols for symptom management and psychological support that could be shared with nonspecialist staff in other health care settings.

CONCLUSION

Our survey suggests that African palliative care services could support the wider health system's response to the COVID-19 pandemic with greater resources such as basic infection control materials. It identified specific and systemic weaknesses impeding their preparedness to respond to outbreaks. The findings call for urgent measures to ensure staff and patient safety.

Rethinking the COVID-19 Pandemic: Back to Public Health

The COVID-19 pandemic has highlighted vast differences across countries in their responses to the emergency and their capacities to implement public health measures that could slow the progression of the disease. As public health systems are the first line of defense during pandemics, it has become clear that sustained investment in strengthening public health infrastructure is a major need in all countries, irrespective of income levels. Drawing on the successful experiences of Switzerland, Georgia, and New Zealand in dealing with COVID-19, we suggest prioritizing core public health capacities with links to the International Health Regulations, improving international cooperation, coordination, and multisectoral action, addressing health inequities by targeting vulnerable groups, and enhancing health literacy, including through sophisticated and sustained communication campaigns to build resilience. These measures will ensure that health systems and communities will be better prepared for the disruptions that future disease outbreaks will inevitably bring.

Africa’s response to the COVID-19 pandemic: A review of the nature of the virus, impacts and implications for preparedness

Background: COVID-19 continues to wreak havoc in different countries across the world, claiming thousands of lives, increasing morbidity and disrupting lifestyles. The global scientific community is in urgent need of relevant evidence, to understand the challenges and knowledge gaps, as well as the opportunities to contain the spread of the virus. Considering the unique socio-economic, demographic, political, ecological and climatic contexts in Africa, the responses which may prove to be successful in other regions may not be appropriate on the continent. This paper aims to provide insight for scientists, policy makers and international agencies to contain the virus and to mitigate its impact at all levels. Methods: The Affiliates of the African Academy of Sciences (AAS), came together to synthesize the current evidence, identify the challenges and opportunities to enhance the understanding of the disease. We assess the potential impact of this pandemic and the unique challenges of the disease on African nations. We examine the state of Africa’s preparedness and make recommendations for steps needed to win the war against this pandemic and combat potential resurgence. Results: We identified gaps and opportunities among cross-cutting issues which is recommended to be addressed or harnessed in this pandemic. Factors such as the nature of the virus and the opportunities for drug targeting, point of care diagnostics, health surveillance systems, food security, mental health, xenophobia and gender-based violence, shelter for the homeless, water and sanitation, telecommunications challenges, domestic regional coordination and financing. Conclusion: Based on our synthesis of the current evidence, while there are plans for preparedness in several African countries, there are significant limitations. Multi-sectoral efforts from the science, education, medical, technological, communication, business and industry sectors as well as local communities is required in order to win this fight.

Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study

BACKGROUND

The novel coronavirus disease 2019 (COVID-19) epidemic has spread from China to 25 countries. Local cycles of transmission have already occurred in 12 countries after case importation. In Africa, Egypt has so far confirmed one case. The management and control of COVID-19 importations heavily rely on a country's health capacity. Here we evaluate the preparedness and vulnerability of African countries against their risk of importation of COVID-19.

METHODS

We used data on the volume of air travel departing from airports in the infected provinces in China and directed to Africa to estimate the risk of importation per country. We determined the country's capacity to detect and respond to cases with two indicators: preparedness, using the WHO International Health Regulations Monitoring and Evaluation Framework; and vulnerability, using the Infectious Disease Vulnerability Index. Countries were clustered according to the Chinese regions contributing most to their risk.

FINDINGS

Countries with the highest importation risk (ie, Egypt, Algeria, and South Africa) have moderate to high capacity to respond to outbreaks. Countries at moderate risk (ie, Nigeria, Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya) have variable capacity and high vulnerability. We identified three clusters of countries that share the same exposure to the risk originating from the provinces of Guangdong, Fujian, and the city of Beijing, respectively.

INTERPRETATION

Many countries in Africa are stepping up their preparedness to detect and cope with COVID-19 importations. Resources, intensified surveillance, and capacity building should be urgently prioritised in countries with moderate risk that might be ill-prepared to detect imported cases and to limit onward transmission.

FUNDING

EU Framework Programme for Research and Innovation Horizon 2020, Agence Nationale de la Recherche.

Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study

BACKGROUND

The novel coronavirus disease 2019 (COVID-19) epidemic has spread from China to 25 countries. Local cycles of transmission have already occurred in 12 countries after case importation. In Africa, Egypt has so far confirmed one case. The management and control of COVID-19 importations heavily rely on a country's health capacity. Here we evaluate the preparedness and vulnerability of African countries against their risk of importation of COVID-19.

METHODS

We used data on the volume of air travel departing from airports in the infected provinces in China and directed to Africa to estimate the risk of importation per country. We determined the country's capacity to detect and respond to cases with two indicators: preparedness, using the WHO International Health Regulations Monitoring and Evaluation Framework; and vulnerability, using the Infectious Disease Vulnerability Index. Countries were clustered according to the Chinese regions contributing most to their risk.

FINDINGS

Countries with the highest importation risk (ie, Egypt, Algeria, and South Africa) have moderate to high capacity to respond to outbreaks. Countries at moderate risk (ie, Nigeria, Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya) have variable capacity and high vulnerability. We identified three clusters of countries that share the same exposure to the risk originating from the provinces of Guangdong, Fujian, and the city of Beijing, respectively.

INTERPRETATION

Many countries in Africa are stepping up their preparedness to detect and cope with COVID-19 importations. Resources, intensified surveillance, and capacity building should be urgently prioritised in countries with moderate risk that might be ill-prepared to detect imported cases and to limit onward transmission.

FUNDING

EU Framework Programme for Research and Innovation Horizon 2020, Agence Nationale de la Recherche.

Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study

BACKGROUND

The novel coronavirus disease 2019 (COVID-19) epidemic has spread from China to 25 countries. Local cycles of transmission have already occurred in 12 countries after case importation. In Africa, Egypt has so far confirmed one case. The management and control of COVID-19 importations heavily rely on a country's health capacity. Here we evaluate the preparedness and vulnerability of African countries against their risk of importation of COVID-19.

METHODS

We used data on the volume of air travel departing from airports in the infected provinces in China and directed to Africa to estimate the risk of importation per country. We determined the country's capacity to detect and respond to cases with two indicators: preparedness, using the WHO International Health Regulations Monitoring and Evaluation Framework; and vulnerability, using the Infectious Disease Vulnerability Index. Countries were clustered according to the Chinese regions contributing most to their risk.

FINDINGS

Countries with the highest importation risk (ie, Egypt, Algeria, and South Africa) have moderate to high capacity to respond to outbreaks. Countries at moderate risk (ie, Nigeria, Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya) have variable capacity and high vulnerability. We identified three clusters of countries that share the same exposure to the risk originating from the provinces of Guangdong, Fujian, and the city of Beijing, respectively.

INTERPRETATION

Many countries in Africa are stepping up their preparedness to detect and cope with COVID-19 importations. Resources, intensified surveillance, and capacity building should be urgently prioritised in countries with moderate risk that might be ill-prepared to detect imported cases and to limit onward transmission.

FUNDING

EU Framework Programme for Research and Innovation Horizon 2020, Agence Nationale de la Recherche.

Towards systematic evaluation of epidemic responses during humanitarian crises: a scoping review of existing public health evaluation frameworks

Epidemics continue to pose a significant public health threat to populations in low and middle-income countries. However, little is known about the appropriateness and performance of response interventions in such settings. We undertook a rapid scoping review of public health evaluation frameworks for emergency settings in order to judge their suitability for assessing epidemic response. Our search identified a large variety of frameworks. However, very few are suitable for framing the response to an epidemic, or its evaluation. We propose a generic epidemic framework that draws on elements of existing frameworks. We believe that this framework may potentially be of use in closing the gap between increasing global epidemic risk and the ability to respond effectively.

Serological evidence of swine exposure to pandemic H1N1/2009 influenza A virus in Burkina Faso

Despite improvement of human and avian influenza surveillance, swine influenza surveillance in sub-Saharan Africa is scarce and pandemic preparedness is still deemed inadequate, including in Burkina Faso. This cross-sectional study therefore aimed to investigate the (past) exposure of pigs to influenza A viruses. Practices of people with occupational contacts with pigs and their knowledge on influenza A were investigated in order to formulate future prevention guidelines. In 2016-2017, pig nasopharyngeal swabs and sera were collected and screened for the presence of influenza virus by RT-PCR or of anti-influenza antibodies by competitive ELISA. Seropositive samples were further characterized in virus microneutralization assays against human and swine H1N1 virus strains. Nasopharyngeal swabs were obtained from people with occupational contact with pigs and screened similarly. Demographic data as well as practices related to their profession were recorded. No influenza A virus was detected in nasopharyngeal swabs in humans (n = 358) or in pigs (n = 600). Seroprevalence in pigs reached 6.8 % (41/600) and seropositive animals were found in 50.0 % of extensive settings (10/20) and 19.0 % of (semi-)intensive farms (4/21). All positive sera reacted against the pandemic H1N1/2009 strain, while seropositivity against two Eurasian avian-like and one American swine H1N1 strains and individual titers were lower. These results suggested exposure to pandemic H1N1/2009 virus and cross-reactivity to other H1N1 strains. Farmers with higher frequency of contact to pigs, absence of protective equipment and lack of knowledge on zoonoses are likely key players in driving human-to-swine virus transmission.