Avian influenza virus (H5N1): a threat to human health

Pandemic influenza virus has its origins in avian influenza viruses. The highly pathogenic avian influenza virus subtype H5N1 is already panzootic in poultry, with attendant economic consequences. It continues to cross species barriers to infect humans and other mammals, often with fatal outcomes. Therefore, H5N1 virus has rightly received attention as a potential pandemic threat. However, it is noted that the pandemics of 1957 and 1968 did not arise from highly pathogenic influenza viruses, and the next pandemic may well arise from a low-pathogenicity virus. The rationale for particular concern about an H5N1 pandemic is not its inevitability but its potential severity. An H5N1 pandemic is an event of low probability but one of high human health impact and poses a predicament for public health. Here, we review the ecology and evolution of highly pathogenic avian influenza H5N1 viruses, assess the pandemic risk, and address aspects of human H5N1 disease in relation to its epidemiology, clinical presentation, pathogenesis, diagnosis, and management.     

禽流感与公共卫生

近年来，H5N1亚型高致病性禽流感在东南亚多个国家爆发，给养禽业带来沉重打击。H5N1亚型禽流感病毒还在越南、泰国、印尼、柬 埔寨和中国引起160多人感染，导致半数以上感染者死亡。禽流感这一重大禽类疫病，目前已成为公共卫生面临的最大威胁。本文对流感及流感病毒、H5N1亚型禽流感病毒跨越禽-哺乳动物种间屏障的分子机制进行了综述，并对今后禽流感的防治提出了建议。     

Transmission of influenza A/H5N1 viruses in mammals

Highly pathogenic avian H5N1 influenza A viruses occasionally infect humans and cause severe respiratory disease and fatalities. Currently, these viruses are not efficiently transmitted from person to person, although limited human-to-human transmission may have occurred. Nevertheless, further adaptation of avian H5N1 influenza A viruses to humans and/or reassortment with human influenza A viruses may result in aerosol transmissible viruses with pandemic potential. Although the full range of factors that modulate the transmission and replication of influenza A viruses in humans are not yet known, we are beginning to understand some of the molecular changes that may allow H5N1 influenza A viruses to transmit via aerosols or respiratory droplets among mammals. A better understanding of the biological basis and genetic determinants that confer transmissibility to H5N1 influenza A viruses in mammals is important to enhance our pandemic preparedness.     

Molecular aspects of avian influenza (H5N1) viruses isolated from humans

In 1997, 18 human infections with H5N1 influenza type A were identified in Hong Kong and six of the patients died. There were concomitant outbreaks of H5N1 infections in poultry. The gene segments of the human H5N1 viruses were derived from avian influenza A viruses and not from circulating human influenza A viruses. In 1999 two cases of human infections caused by avian H9N2 virus were also identified in Hong Kong. These events established that avian influenza viruses can infect humans without passage through an intermediate host and without acquiring gene segments from human influenza viruses. The likely origin of the H5N1 viruses has been deduced from molecular analysis of these and other viruses isolated from the region. The gene sequences of the H5N1 viruses were analysed in order to identify the molecular basis for the ability of these avian viruses to infect humans.     

禽H9N2亚型流感病毒能感染人的发现

目的了解禽（Ｈ９Ｎ２）亚型流感病毒是否能感染人。方法对人、鸡和猪进行Ｈ９亚型毒株血清流行病学调查。对流感样患者和鸡咽喉部采样,用常规鸡胚双腔法分离流感病毒并进行毒株鉴定。对分离出Ｈ９Ｎ２亚型毒株的患者进行个案调查。结果约１９％的人含有对Ｈ９Ｎ２毒株的抗体,其ＨＩ滴度为≥２０,从流感样患者中分离到５株Ｈ９Ｎ２病毒。结论Ｈ９Ｎ２亚型毒株能自然感染人。     

中国职业暴露人群感染H6N6禽流感病毒血清学调查

目的 系统评估我国职业暴露人群感染H6N6禽流感病毒的状况.方法 本研究利用我国2009-2011年开展的高致病性H5N1禽流感病毒职业暴露人群血清学监测所采集的近15 000份血清标本,开展H6N6禽流感病毒血清学调查.结果 本研究中检测到H6N6禽流感病毒阳性血清共10份,分别来自不同的职业暴露人群,包括活禽市场、家禽规模养殖场、家禽散养户、屠宰加工场和野生候鸟栖息地.从地域上看该10份阳性血清来自8个不同的省份,分布在我国的南北方.结论 这是我国大陆地区首次报道人感染H6亚型禽流感病毒.     

H5N1型禽流感病毒动物模型的研究现状

H5N1亚型禽流感病毒在全球多个国家肆虐,已严重威胁人类健康。禽流感病毒动物模型的建立可以为研究病毒的突变、传染性和发病机制提供良好的技术平台。本综述概括了H5N1对几种哺乳动物:食蟹猴、雪貂、小鼠、大鼠、沙鼠、家猫等的致病性,为以后理想动物模型的建立和研究提供一定的帮助。     

The threat of avian influenza a (H5N1): part II: Clues to pathogenicity and pathology

Among emerging and re-emerging infectious diseases, influenza constitutes one of the major threats to mankind. In this review series epidemiologic, virologic and pathologic concerns raised by infections of humans with avian influenza virus A/H5N1 are discussed. The second part focuses on experimental and clinical results, which give insights in the pathogenic mechanisms of H5N1 infection in humans. H5N1 is poorly transmitted to humans. However, H5N1-induced disease is very severe. More information on the role entry barriers, H5N1 target cells and on H5N1-induced modulation of the host immune response is needed to learn more about the determinants of H5N1 pathogenicity.     

Avian influenza virus in pregnancy

The unprecedented epizootic of avian influenza viruses, such as H5N1, H5N6, H7N1 and H10N8, has continued to cause disease in humans in recent years. In 2013, another novel influenza A (H7N9) virus emerged in China, and 30% of those patients died. Pregnant women are particularly susceptible to avian influenza and are more likely to develop severe complications and to die, especially when infection occurs in the middle and late trimesters. Viremia is believed to occur infrequently, and thus vertical transmission induced by avian influenza appears to be rare. However, avian influenza increases the risk of adverse pregnancy outcomes, including spontaneous abortion, preterm birth and fatal distress. This review summarises 39 cases of pregnant women and their fetuses from different countries dating back to 1997, including 11, 15 and 13 infections with H7N9, H5N1 and the 2009 pandemic influenza (H1N1), respectively. We analysed the epidemic features, following the geographical, population and pregnancy trimester distributions; underlying diseases; exposure history; medical timelines; human‐to‐human transmission; pathogenicity and vertical transmission; antivirus treatments; maternal severity and mortality and pregnancy outcome. The common experiences reported in different countries and areas suggest that early identification and treatment are imperative. In the future, vigilant virologic and epidemiologic surveillance systems should be developed to monitor avian influenza viruses during pregnancy. Furthermore, extensive study on the immune mechanisms should be conducted, as this will guide safe, rational immunomodulatory treatment among this high‐risk population. Most importantly, we should develop a universal avian influenza virus vaccine to prevent outbreaks of the different subtypes. Copyright © 2016 John Wiley & Sons, Ltd.     

Comparative analytical sensitivities of six rapid influenza A antigen detection test kits for detection of influenza A subtypes H1N1, H3N2 and H5N1.

BACKGROUND: Rapid and simple methods for diagnosing human influenza A (H5N1) disease urgently needed. The limited data so far suggest that the currently available rapid antigen detection kits have poor clinical sensitivity for diagnosis of human H5N1 disease. OBJECTIVES: To compare the analytical sensitivity of six commercially available rapid antigen detection kits for the detection of "human" (subtypes H1N1, H3N2) and "avian" (subtype H5N1) influenza A viruses. STUDY DESIGN: Six commercially available test kits for the detection of influenza A were investigated. Analytic sensitivity for the detection of two contemporary H1N1, two H3N2 and three H5N1 viruses was determined using virus culture as a reference method. RESULTS AND CONCLUSIONS: Each test kit detected the H5N1 virus subtypes as efficiently as they detected conventional human viruses of subtypes H1N1 or H3N2. However, limits of detection of influenza viruses of all subtypes by antigen detection kits were >1000-fold lower than virus isolation. Thus, the reportedly poor clinical sensitivity of these antigen detection kits for diagnosis of patients with H5N1 disease is not due to a difference of sensitivity for detecting avian influenza H5N1 compared to human influenza viruses.     

Mutations of neuraminidase implicated in neuraminidase inhibitors resistance.

Influenza constitutes one of the most important upper respiratory tract infections regarding morbidity, and mortality. Prevention and treatment of influenza rely on inactivated vaccines and antiviral drugs. Zanamivir and Oseltamivir, the currently available influenza neuraminidase inhibitors (NAI) can be used in clinical practice for the treatment of influenza infection. These drugs have also shown their efficacy against highly pathogenic avian influenza. Recent transmission of avian H7N7 and H5N1 influenza virus to human emphasized the need for active antiviral against emerging influenza viruses. Since their introduction in clinical practice, numerous studies have been implemented to determine the rate of emergence of NAI resistant isolates. These studies describe mechanisms of resistance associated to mutations in the neuraminidase protein, and their consequence in virus fitness and transmission. This review is summarizing the mutations described in human and avian influenza neuraminidases that are associated to resistance or reduction in sensitivity.     

Cellular response to influenza virus infection: a potential role for autophagy in CXCL10 and interferon-alpha induction

Historically, influenza pandemics have arisen from avian influenza viruses. Avian influenza viruses H5N1 and H9N2 are potential pandemic candidates. Infection of humans with the highly pathogenic avian influenza H5N1 virus is associated with a mortality in excess of 60%, which has been attributed to dysregulation of the cytokine system. Human macrophages and epithelial cells infected with some genotypes of H5N1 and H9N2 viruses express markedly elevated cytokine and chemokine levels when compared with seasonal influenza A subtype H1N1 virus. The mechanisms underlying this cytokine and chemokine hyperinduction are not fully elucidated. In the present study, we demonstrate that autophagy, a tightly regulated homeostatic process for self-digestion of unwanted cellular subcomponents, plays a role in cytokine induction. Autophagy is induced to a greater extent by H9N2/G1, in association with cytokine hyperinduction, compared with H1N1 and the novel pandemic swine-origin influenza A/H1N1 viruses. Using 3-methyladenine to inhibit autophagy and small interfering RNA to silence the autophagy gene, Atg5, we further show that autophagic responses play a role in influenza virus-induced CXCL10 and interferon-α expression in primary human blood macrophages. Our results provide new insights into the pathogenic mechanisms of avian influenza viruses.     

Avian influenza virus isolates from wild birds replicate and cause disease in a mouse model of infection

The direct transmission of highly pathogenic avian influenza (HPAI) viruses to humans in Eurasia and subsequent disease has sparked research efforts leading to better understanding of HPAI virus transmission and pathogenicity in mammals. There has been minimal focus on examining the capacity of circulating low pathogenic wild bird avian influenza viruses to infect mammals. We have utilized a mouse model for influenza virus infection to examine 28 North American wild bird avian influenza virus isolates that include the hemagglutinin subtypes H2, H3, H4, H6, H7, and H11. We demonstrate that many wild bird avian influenza viruses of several different hemagglutinin types replicate in this mouse model without adaptation and induce histopathologic lesions similar to other influenza virus infections but cause minimal morbidity. These findings demonstrate the potential of wild avian influenza viruses to directly infect mice without prior adaptation and support their potential role in emergence of pandemic influenza.     

Evolution of avian influenza viruses H5N1 (1997-2004) in southern and south-eastern Asia

Highly pathogenic avian influenza viruses of the H5N1 subtype are widespread and have become endemic in poultry in southern and southeastern Asia. An unprecedented epizootic was caused by these viruses in 8 countries in the winter of 2003 to 2004. This fact along with more frequent human cases of the infection with unusually high mortality rates in Vietnam and Thailand raises concern that these H5N1 events may lead to a new influenza A virus pandemic. This review summarizes the results of studies dealing with the ecology and evolution of avian influenza H5N1 viruses in southern and southeastern Asia since 1997. The pathogenesis of the infection in human beings and laboratory animals and possible determinants of the high pathogenicity of H5N1 viruses in mammals are considered. A scheme for designing modified H5N1 vaccines using the latest advances in reverse genetics of influenza viruses is given.     

Histopathological Evaluation of the Diversity of Cells Susceptible to H5N1 Virulent Avian Influenza Virus

Patients infected with highly pathogenic avian influenza A H5N1 viruses (H5N1 HPAIV) show diffuse alveolar damage. However, the temporal progression of tissue damage and repair after viral infection remains poorly defined. Therefore, we assessed the sequential histopathological characteristics of mouse lung after intranasal infection with H5N1 HPAIV or H1N1 2009 pandemic influenza virus (H1N1 pdm). We determined the amount and localization of virus in the lung through IHC staining and in situ hybridization. IHC used antibodies raised against the virus protein and antibodies specific for macrophages, type II pneumocytes, or proliferating cell nuclear antigen. In situ hybridization used RNA probes against both viral RNA and mRNA encoding the nucleoprotein and the hemagglutinin protein. H5N1 HPAIV infection and replication were observed in multiple lung cell types and might result in rapid progression of lung injury. Both type II pneumocytes and macrophages proliferated after H5N1 HPAIV infection. However, the abundant macrophages failed to block the viral attack, and proliferation of type II pneumocytes failed to restore the damaged alveoli. In contrast, mice infected with H1N1 pdm exhibited modest proliferation of type II pneumocytes and macrophages and slight alveolar damage. These results suggest that the virulence of H5N1 HPAIV results from the wide range of cell tropism of the virus, excessive virus replication, and rapid development of diffuse alveolar damage.Seasonal, pandemic, and zoonotic influenza A virus infections show substantial morbidity and mortality in humans. Seasonal influenza A virus infections in humans are usually mild and cause pneumonia only in a few infected individuals. Pandemic influenza virus infections vary in their disease outcome. Zoonotic influenza virus infections in humans vary from self-limiting conjunctivitis to severe, often fatal, pneumonia. Highly pathogenic avian influenza H5N1 virus (H5N1 HPAIV), implicated in poultry outbreaks,^1,2 can be transmitted zoonotically to humans, as has been observed in areas of Asia and Africa.^3–5 Fatal outcomes have been reported at approximately 60% in the sporadic transmission of this avian influenza H5N1 virus to humans.^5–7 There is no evidence that the avian influenza virus has become efficiently transmissible among humans, a change that could result in a new pandemic.⁸The outcome after infection with influenza virus can range from slight to severe illness, depending on the kinds of cells that are affected during lung tissue infection.^9–11 Events occurring early in infection determine the extent of damage, which can range from bronchitis to pneumonia. In the most severe cases, diffuse alveolar damage (DAD) may be induced during the early stages, and healing and/or scarring may ensue, depending on the persistence of disease. Occasionally, bacterial infection also may occur, with associated effects expressed mainly in the later stages of the disease. Pathological damage caused by influenza viruses in humans and in animal models depends on the virulence of the infective agent and on the host response. All influenza viruses infect the respiratory tract epithelium from the nasal passages to the bronchioles; however, highly virulent viruses (eg, H1N1 1918 and H5N1 HPAIV) tend to infect pneumocytes and resident macrophages in the alveoli. In susceptible individuals, inflammation of the alveolar walls results in DAD. In contrast, low-virulence viruses (seasonal H1N1) primarily cause inflammation, congestion, and epithelial necrosis of the trachea, bronchi, and bronchioles. Tissue tropism is an important factor, and depends largely on the ability of the virus to attach to the host cell.^12–14 We investigated virus replication and histopathological progression of lung tissue in mice infected with H5N1 HPAIV, particularly focusing on the lower respiratory tract and alveoli, with direct comparison to the histopathological characteristics of mice infected with H1N1 pandemic (pdm) influenza virus 2009 virus.     

Molecular changes associated with the transmission of avian influenza a H5N1 and H9N2 viruses to humans.

In order to identify molecular changes associated with the transmission of avian influenza A H5N1 and H9N2 viruses to humans, the internal genes from these viruses were compared to sequences from other avian and human influenza A isolates. Phylogenetically, each of the internal genes of all sixteen of the human H5N1 and both of the H9N2 isolates were closely related to one another and fell into a distinct clade separate from clades formed by the same genes of other avian and human viruses. All six internal genes were most closely related to those of avian isolates circulating in Asia, indicating that reassortment with human strains had not occurred for any of these 18 isolates. Amino acids previously identified as host-specific residues were predominantly avian in the human isolates although most of the proteins also contained residues observed previously only in sequences of human influenza viruses. For the majority of the nonglycoprotein genes, three distinct subgroups could be distinguished on bootstrap analyses of the nucleotide sequences, suggesting multiple introductions of avian virus strains capable of infecting humans. The shared nonglycoprotein gene constellations of the human H5N1 and H9N2 isolates and their detection in avian isolates only since 1997 when the first human infections were detected suggest that this particular gene combination may confer the ability to infect humans and cause disease. J. Med. Virol. 66:107-114, 2002. Published 2002 Wiley-Liss, Inc.     

Pandemic threat posed by avian influenza A viruses

Influenza pandemics, defined as global outbreaks of the disease due to viruses with new antigenic subtypes, have exacted high death tolls from human populations. The last two pandemics were caused by hybrid viruses, or reassortants, that harbored a combination of avian and human viral genes. Avian influenza viruses are therefore key contributors to the emergence of human influenza pandemics. In 1997, an H5N1 influenza virus was directly transmitted from birds in live poultry markets in Hong Kong to humans. Eighteen people were infected in this outbreak, six of whom died. This avian virus exhibited high virulence in both avian and mammalian species, causing systemic infection in both chickens and mice. Subsequently, another avian virus with the H9N2 subtype was directly transmitted from birds to humans in Hong Kong. Interestingly, the genes encoding the internal proteins of the H9N2 virus are genetically highly related to those of the H5N1 virus, suggesting a unique property of these gene products. The identification of avian viruses in humans underscores the potential of these and similar strains to produce devastating influenza outbreaks in major population centers. Although highly pathogenic avian influenza viruses had been identified before the 1997 outbreak in Hong Kong, their devastating effects had been confined to poultry. With the Hong Kong outbreak, it became clear that the virulence potential of these viruses extended to humans.     

广州地区禽H9N2亚型流感病毒的发现及感染人调查

目的 了解广州地区禽流感病毒在家禽中的流行及感染人的情况，防止香港H5N1禽流感在广州地区流行。方法 对广州地区的主要鸡场和农贸市场的家禽和密切接触家禽的职业人群进行病原学和血清学的检测。病毒分离同时采用MDCK细胞和鸡胚双腔接种法；采用微量血凝抑制半致敏法进行血清学检测。结果 从54份鸡咽拭液中分离到1株H9N2亚型流感病毒；鸡及职业人群血对分离的H9N2毒株的血抑抗体阳性率分别为12．8％和15．1％。结论 广州地区鸡群中有H9N2，亚型流感病毒存在，禽H9N2亚型流感病毒能感染人。     

A novel H1N1 virus causes the first pandemic of the 21st century

A novel H1N1 virus of swine origin (H1N1v ) is currently spreading in humans, giving rise to the first pandemic in 40 years. The disease is of moderate severity but has notable differences from seasonal influenza. In contrast to seasonal influenza, those over 60 years are relatively spared, a likely consequence of the presence of H1N1v cross‐neutralizing antibody in this age group. Most patients appear to have mild influenza‐like illness and many of the complications leading to hospitalization and mortality occur in those with underlying disease conditions or pregnancy. Studies in animal models suggest that the novel H1N1v pandemic virus causes a more severe illness and appears to have a greater predilection for the alveolar epithelium than seasonal influenza viruses. As there are as yet little data on the pathogenesis and immunology of H1N1v infection in humans, we have reviewed relevant data from past pandemics, from seasonal influenza and avian influenza H5N1 to highlight key issues pertaining to pathogenesis and immunology.