Zoonotic Influenza and Human Health—Part 2: Clinical Features,Diagnosis, Treatment,and Prevention Strategies

Purpose of Review

Zoonotic influenza viruses are those influenza viruses that cross the animal-human barrier and can cause disease in humans, manifesting from minor respiratory illnesses to multiorgan dysfunction. The increasing incidence of infections caused by these viruses worldwide has necessitated focused attention to improve both diagnostic as well as treatment modalities. In this second part of a two-part review, we discuss the clinical features, diagnostic modalities, and treatment of zoonotic influenza, and provide an overview of prevention strategies.

Recent Findings

Illnesses caused by novel reassortant avian influenza viruses continue to be detected and described; most recently, a human case of avian influenza A(H7N4) has been described from China. We continue to witness increasing rates of A(H7N9) infections, with the latest (fifth) wave, from late 2016 to 2017, being the largest to date. The case fatality rate for A(H7N9) and A(H5N1) infections among humans is much higher than that of seasonal influenza infections. Since the emergence of the A(H1N1) 2009 pandemic, and subsequently A(H7N9), testing and surveillance for novel influenzas have become more effective. Various newer treatment options, including peramivir, favipiravir (T-705), and DAS181, and human or murine monoclonal antibodies have been evaluated in vitro and in animal models.

Summary

Armed with robust diagnostic modalities, antiviral medications, vaccines, and advanced surveillance systems, we are today better prepared to face a new influenza pandemic and to limit the burden of zoonotic influenza than ever before. Sustained efforts and robust research are necessary to efficiently deal with the highly mutagenic zoonotic influenza viruses.

     

Group 1 Vaccinia virus Zoonotic Outbreak in Maranh?o State,Brazil

In Brazil, several exanthematic autochthone Vaccinia virus (VACV) outbreaks affecting dairy cattle and rural workers have been reported since 1999. Although outbreaks had been first described in the Brazilian Southeast, VACV outbreaks were notified in all Brazilian regions in < 10 years. However, in this context, VACV outbreaks had not been described in some Brazilian States, likely because of a lack of notification, or yet unknown epidemiological reasons. Here, we describe the first VACV outbreak in Maranhão State, northeastern Brazil. The virus isolated from this outbreak showed several biological and molecular features that resemble other Group 1 Brazilian VACV, including a deletion signature in the A56R gene. This study raises new questions about diversity and epidemiology of Brazilian VACV.After centuries of epidemics and deaths, smallpox was declared eradicated in 1980, after an intensive vaccination campaign promoted by the World Health Organization (WHO).^1,2 The smallpox vaccines used in the WHO campaign were, in fact, strains of the Vaccinia virus (VACV), a species belonging to the genus Orthopoxvirus (OPV), which induced serological cross-reactivity against other OPV members, including Variola virus (the agent of smallpox).^1,2 Despite the immune protection provided by VACV, several cases of adverse manifestations caused by vaccination were reported, which led to the suspension of the vaccination after the disease eradication.³ However, the suspension of the smallpox vaccination led to the emergence of a generation that is susceptible to infection by other OPV species, such as 1) Cowpox virus (CPXV) in Europe; 2) Monkeypox virus (MPXV), which occurs naturally in Africa with one introduction event reported from the United States; and 3) VACV in Asia and South America.^4–6In Brazil, several exanthematic autochtonous VACV outbreaks affecting dairy cattle and rural workers have been reported since 1999.^4,7 The disease has a great impact on the Brazilian milk industry and public health services.^4,7 During these outbreaks, infected dairy cattle usually presented ulcerative lesions on their teats and udders and had decreased milk production.^8,9 Rural workers who were infected with VACV, most likely from occupational contact with infected cattle, usually presented lesions on their hands and arms, lymphadenopathy, high fever, and prostration, among other symptoms.^8,9 Since early reports of VACV outbreaks in Brazil, several VACV isolates have been characterized.^4,7–9 Molecular and biological studies have shown that Brazilian VACV isolates can be divided into two distinct groups: Group 1 and Group 2.^10,11 The Group 1 VACV-BR comprises Cantagalo, Araçatuba, Passatempo, GuaraniP2, Mariana, Pelotas2, DMTV, and other isolates; Group 2 VACV-BR includes GuaraniP1, Pelotas1, SH2V, Bean58058, and other isolates.^10,11 Although outbreaks had been first described in Brazilian Southeast, VACV had spread to all Brazilian regions in < 10 years. In this context, VACV outbreaks had not been described in some Brazilian States, likely because of lack of notification, or yet unknown epidemiological reasons. Here, we describe the first VACV outbreak in Maranhão State, northeastern Brazil.In February 2009, an exanthematic VACV outbreak was reported in the rural region of Açailândia County (04°56′49″S 47°30′18″W), Maranhão State, Brazil. This region is characterized by the presence of small rural properties, where cattle are kept for milk production. During this outbreak, several animals (42 bovine cattle) and farm workers (6 patients) from neighboring properties presented exanthematous lesions similar to those reported during other Brazilian bovine VACV outbreaks.^4,7–9 A total of 9 farms were affected by this bovine vaccinia outbreak. The origin of this outbreak is unknown, but workers were most likely infected while milking infected animals and transmitted the virus by direct contact with healthy animals at the other properties. Although previous studies had shown the importance of peridomestic rodents in bovine vaccinia outbreaks,⁷ the capture of rodents was not performed during the outbreak. A total of three farms that were affected during the outbreak were visited, and epithelial samples (three dried scabs) from three infected dairy cows were collected (a sample was collected per farm) with tweezers, kept under refrigeration, and sent to our laboratory for etiological agent identification. The scabs were macerated using a homogenizer (Politron, Littau, Switzerland) in phosphate buffered saline (PBS), which contained 200 U/mL penicillin, 4 μg/mL amphotericin B, and 100 μg/mL gentamicin (0.1 g scab/0.9 mL PBS), and centrifuged at 2000 × g for 3 min. The resulting supernatants were used for diagnostic purposes, viral isolation, and molecular assays.¹²To confirm if the etiological agent of the outbreak was an OPV, the sample supernatants were diluted 1:100 in PBS and used as templates for a polymerase chain reaction (PCR) that targeted a partial region of viral growth factor gene (vgf). The reactions were carried out by adding 2 μL of the template to 18 μL of the PCR reaction mixture that contained 0.4 mM of vgf primers, as previously described.¹³ The PCR products were electrophoresed in 8%-PAGE gels and silver stained.¹⁴For viral isolation, 300 μL of the sample was added onto BSC-40 cell monolayers that were grown in a six-well plate and incubated at 37°C for 72 hours or until detection of the cytopathic effect (CPE). After CPE observation, the cells were harvested and new BSC-40 cell monolayers were reinoculated for viral amplification. The resulting viruses were purified in a sucrose gradient and titrated as described.^15,16 For plaque phenotype assays, BSC-40 cell monolayers at 90–95% confluency were infected with a multiplicity of infection (MOI) of 0.01 of the new isolate, GP1V (as a large-plaque control) and GP2V isolates (as a small-plaque control). The VACV-WR strain and PBS were used as additional controls. Forty-eight hours after infection, the cells were fixed with paraformaldehyde and stained with crystal violet for plaque size analysis.Attempts at viral isolation revealed typical pox-like CPEs in BSC-40 cells that were inoculated with supernatants from the three tested scabs. No cellular changes were observed in the BSC-40 monolayer that was inoculated with PBS control. In parallel, the nested-PCR assay that targets C11R¹³ resulted in the amplification of OPV-specific fragments in all tested samples (three scabs) that were also present in the VACV-WR positive control. Because all tested samples were identical in biological and molecular tests, the isolate was named Maranhão virus (MRV).After amplifying and purifying MRV, plaque phenotype assays were performed to evaluate the biological cluster of this new isolate. Previously, Brazilian OPV isolates have been clustered into two distinct groups, Group 1 and Group 2. Compared with GP1V (Group 2) and GP2V (Group 1) in plaque assays, MRV plaques were small and similar to those formed by GP2V, which provides supporting evidence to classify MRV as a member of Group 1 VACV. As expected, VACV-WR produced large plaques similar to those associated with GP1V (data not shown).For molecular characterization, viral genes such as the highly conserved TK gene (thymidine kinase)¹⁷ and the variable A56R gene (hemagglutinin, HA)^18,19 were amplified and sequenced for phylogenetic analysis. The chemistry and thermal conditions of these PCR reactions were similar to those used for the vgf nested-PCR; however, the annealing temperatures of the specific primers were changed. The PCR fragments obtained from this study were sequenced in both orientations and in triplicates (Mega-BACE 1000 sequencer) (GE Healthcare, Buckinghamshire, UK). The sequences were aligned with previously published OPV sequences from GenBank using the ClustalW method, and the alignments were checked manually with the MEGA version 4.0 software (Arizona State University, Phoenix, AZ). Accession numbers for the analyzed sequences can be found in their respective figures. Maximum likehood trees were reconstructed using different data sets containing sequences from the genes listed previously, using MEGA 4.0. Using the ModelTest Server,¹⁹ the nucleotide substitution model of Tamura 1992 was selected as the best one fitting the data. Rates of variation among sites were estimated for each data set and two discrete Gamma categories were used to model evolutionary rate differences among sites and the reliability of branching patterns was tested through 1,000 bootstrap sampling. The MRV sequences obtained in this study were deposited in GenBank: 1640002 and 1639939 (provisional).The TK sequences of MRV indicate that the isolate clusters with other VACV isolates (Figure 1A). Because of the conservation of the nucleotide sequences, TK can serve as a genetic marker for OPV species identification; however, it provides limited information for VACV sub-cluster analysis. Phylogenetic analyses of A56R sequences clustered MRV with Group 1 Brazilian VACV isolates (Figure 1B), confirming our biological data. The hemagglutinin gene nucleotides were analyzed by alignment with similar sequences from other OPV isolates deposited in GenBank. The MRV A56R sequence contained a signature deletion (Figure 1C) also present in the sequences of other Brazilian Group 1 VACV isolates, such as Araçatuba virus (ARAV), Cantagalo virus (CTGV), Serro virus (SV2), GuaraniP2 virus (GP2V), Muriae virus (MURV), and others, but absent in Group 2 VACV, such as GuaraniP1 virus (GP1V), Belo Horizonte virus (VBH), BeAn58058 virus (BAV), and SPAn232 virus (SAV). Although some Group 1 VACV present exclusive nt substitutions, phylogenetic analysis do not support the prediction of a progenitor (sub-branches with low bootstrap P values—data not shown).Open in a separate windowFigure 1.(A) Phylogenetic tree generated from OPV TK nucleotide sequences, including the Brazilian Vaccinia virus (VACV) isolates. The colored boxes are species-related (VACV, orange; VARV, green; CPXV, blue; and MPXV, pink). The OPV clusters (colored boxes) are strongly supported by high bootstrap P values. The Maranhão isolate is depicted as a black dot. (B) Phylogenetic tree generated from OPV A56R nucleotide sequences, including the Brazilian VACV isolates. A56R phylogenetic analyses showed that the Brazilian VACV isolates are split into two different branches (Groups 1 and 2). Maranhão isolate clustered with Group 1 VACV isolates. Maximum likehood trees were reconstructed using different data sets containing sequences from the genes listed previously, using MEGA 4.0. Gamma categories were used to model evolutionary rate differences among sites and the reliability of branching patterns was tested through 1,000 bootstrap sampling. (C) Nucleotide sequence alignment of A56R coding DNA sequences. Sequences were retrieved from GenBank and aligned using the ClustalW method as implemented in the MEGA 4.0 program. The Maranhão isolate showed an 18-nt deletion. The same deletion was observed in the Brazilian VACV Group 1 isolates. Nevertheless, the Brazilian Group 2 isolates had no deletion in A56R. The deletion site is highlighted with an asterisk.Taken together, our results showed that MRV is a new Group 1 Brazilian VACV strain that was isolated from a zoonotic vaccinia outbreak in the northeastern region of Brazil. Farming and dairy production are important activities in this region and were negatively impacted by the bovine vaccinia outbreaks. The infection of rural workers has public health implications. This is also the first characterization of a VACV isolated during an outbreak in Maranhão State. Transmission of VACV in northeastern Brazil has been reported, and outbreaks have been notified in Pernambuco, Tocantins, Bahia, and Pará States²¹, which are close to Maranhão (Figure 2). Although our team was not able to screen the source of this outbreak, we believe that MRV could derivate from the virus(es) that circulate(s) in those neighbors States. The VACV has also been detected in wild monkeys in the Brazilian Amazon,²¹ therefore the role of wild life in VACV spread and maintenance could not be neglected, especially in states where the forest is present, such as Maranhão State. Some of these viruses may be related to that isolated in this study because some VACV isolates have the same signature deletion in the HA gene as MRV. We believe that veterinary surveillance, farm worker education, inspection of farm workers and cattle before milking, and quarantine of sick animals are sine qua non conditions for controlling viruses. New ecological and epidemiological studies could also help to explain why VACV has spread in the last decade State-by-State, through Brazilian rural areas.Open in a separate windowFigure 2.Map highlighting Group 1 and Group 2 VACV circulation in Brazil. MRV was isolated from Maranhão State.     

Simian Foamy Virus in Non-Human Primates and Cross-Species Transmission to Humans in Gabon: An Emerging Zoonotic Disease in Central Africa?

It is now known that all human retroviruses have a non-human primate counterpart. It has been reported that the presence of these retroviruses in humans is the result of interspecies transmission. Several authors have described the passage of a simian retrovirus, simian foamy virus (SFV), from primates to humans. To better understand this retroviral “zoonosis” in natural settings, we evaluated the presence of SFV in both captive and wild non-human primates and in humans at high risk, such as hunters and people bitten by a non-human primate, in Gabon, central Africa. A high prevalence of SFV was found in blood samples from non-human primates and in bush meat collected across the country. Mandrills were found to be highly infected with two distinct strains of SFV, depending on their geographical location. Furthermore, samples collected from hunters and non-human primate laboratory workers showed clear, extensive cross-species transmission of SFV. People who had been bitten by mandrills, gorillas and chimpanzees had persistent SFV infection with low genetic drift. Thus, SFV is presumed to be transmitted from non-human primates mainly through severe bites, involving contact between infected saliva and blood. In this review, we summarize and discuss our five-year observations on the prevalence and dissemination of SFV in humans and non-human primates in Gabon.     

Monitoring Urban Zoonotic Virus Activity: Are City Rats a Promising Surveillance Tool for Emerging Viruses?

Urban environments represent unique ecosystems where dense human populations may come into contact with wildlife species, some of which are established or potential reservoirs for zoonotic pathogens that cause human diseases. Finding practical ways to monitor the presence and/or abundance of zoonotic pathogens is important to estimate the risk of spillover to humans in cities. As brown rats (Rattus norvegicus) are ubiquitous in urban habitats, and are hosts of several zoonotic viruses, we conducted longitudinal sampling of brown rats in Vienna, Austria, a large population center in Central Europe. We investigated rat tissues for the presence of several zoonotic viruses, including flaviviruses, hantaviruses, coronaviruses, poxviruses, hepatitis E virus, encephalomyocarditis virus, and influenza A virus. Although we found no evidence of active infections (all were negative for viral nucleic acids) among 96 rats captured between 2016 and 2018, our study supports the findings of others, suggesting that monitoring urban rats may be an efficient way to estimate the activity of zoonotic viruses in urban environments.     

Anomaly and tumor of kidney and urinary tract

2007475 MRI manifestations of renal oncocytoma.JI Jiansong(纪建松) , et al. Dept Radiol, Sir Run RunShaw Hosp, Zhejiang Univ, Hangzhou 310016. Chin JRadiol 2007;41(10):1087 -1089. Objective To analyze the MRI findings of renal on-cocytoma, and to improve the ability for the diagnosis.Methods We retrospectively reviewed MRI findings ofsults Sixcases had a solitary lesion, and 1 of themac-companied with renal clear-cell carcinoma. Tumors ap-peared as round with diameter 1.5 to 3.8 cm,…     

Relationships between serum adiponectin and soluble TNF-α receptors and glucose and lipid oxidation in lean and obese subjects

Insulin resistance might be associated with an impaired ability of insulin to stimulate glucose oxidation and inhibit lipid oxidation. Insulin action is also inversely associated with TNF-α system and positively related to adiponectin. The aim of the present study was to analyze the associations between serum adiponectin, soluble TNF-α receptors concentrations and the whole-body insulin sensitivity, lipid and glucose oxidation, non-oxidative glucose metabolism (NOGM) and metabolic flexibility in lean and obese subjects. We examined 53 subjects: 25 lean (BMI < 25 kg × m⁻²) and 28 with overweight or obesity (BMI > 25 kg × m⁻²) with normal glucose tolerance. Hyperinsulinemic euglycemic clamp and indirect calorimetry were performed. An increase in respiratory exchange ratio in response to insulin was used as a measure of metabolic flexibility. Obese subjects had lower insulin sensitivity, adiponectin and higher sTNFR1 (all P < 0.001) and sTNFR2 (P = 0.001). Insulin sensitivity was positively related to adiponectin (r = 0.49, P < 0.001) and negatively related to sTNFR1 (r = −0.40, P = 0.004) and sTNFR2 (r = −0.52, P < 0.001). Adiponectin was related to the rate of glucose (r = 0.47, P < 0.001) and lipid (r = −0.40, P = 0.003) oxidation during the clamp, NOGM (r = 0.41, P = 0.002) and metabolic flexibility (r = 0.36, P = 0.007). Serum sTNFR1 and sTNFR2 were associated with the rate of glucose (r = −0.45, P = 0.001; r = −0.51, P < 0.001, respectively) and lipid (r = 0.52, P < 0.001; r = 0.46, P = 0.001, respectively) oxidation during hyperinsulinemia, NOGM (r = −0.31, P = 0.02; r = −0.43, P = 0.002, respectively) and metabolic flexibility (r = −0.47 and r = −0.51, respectively, both P < 0.001) in an opposite manner than adiponectin. Our data suggest that soluble TNF-α receptors and adiponectin have multiple effects on glucose and lipid metabolism in obesity.     

Periodontitis and diabetes mellitus—an awareness and perception study among endocrinologists and diabetologists

International Journal of Diabetes in Developing Countries - Periodontitis is a chronic inflammatory disease caused by pathogenic dental plaque which causes microbial dysbiosis leading to...     

Rest and Relax

Life is made up of exercise and activity;but,if life is to continue for any extended time,there must also be rest and relaxation.A bal-ance between activity and rest is the objectiveof all intelligent living-not too much activity,yet not too much rest.Life for most people is a very unbalancedaffair.Jobs in modern industry are so special-ized that usually one part or one set of organsof the body is overstrained while others arealways in need of exereise.Much of the fatigue and strain from thework we do today is the result of unnecessarytension.Every job we do requires that certain     

Endocrinology and Metabolism

2020036 Comparative analysis of clinical features of fulminant type 1 diabetes.WANG Yajing(王雅静),et al.Dept Endocrinol,1st Med Center,Chin PLA General Hosp,Beijing 100853.Med J Chin PLA 2019;44(11):937-94.Objective To analyze and compare the clinical features of fulminant type 1 diabetes mellitus(FT1D M).     

Lipids,Lipoproteins, and Metabolites and Risk of Myocardial Infarction and Stroke

Background

Blood lipids are established risk factors for myocardial infarction (MI), but uncertainty persists about the relevance of lipids, lipoprotein particles, and circulating metabolites for MI and stroke subtypes.

Thromboelastography and recombinant factor VIIa—hemophilia and beyond

Thromboelastography (TEG), which records the continuous profiles of whole blood (WB) coagulation, can be used to evaluate the effects of hemostatic agents, such as recombinant factor VII (rFVIIa). Our group has developed a revised TEG model, involving activation with minute amounts of tissue factor and subsequent signal processing, and has used this method to evaluate the effects of rFVIIa both in patients with hemophilia and in those receiving vitamin K antagonist (VKA) thromboprophylaxis. We review the early results of our investigations, which suggest that, in clinical situations where rFVIIa has shown benefit, the changes in the profiles obtained by TEG recording appear to correlate with the clinical outcome.     

Alcohol and Atherosclerosis

Objectives To study the relationship between alcohol and atherosclerosis （AS）. Methods The paper reviewed the mechanism of the alcohol leading to AS from four aspects such as the introduction of alcohol and AS, imbalance of oxidationantioxidation system, oxygen free radical （OFR） and endothelium cell （EC） apoptosis, apoptosis and AS. Results Excessive alcohol could lead to imbalance of oxidation-antioxidation system, and increase OFR, in the meanwhile, OFR could lead to EC apoptosis, which could lead to AS.     

Meetings and Courses

Announcements for this section should be submitted in the correct format at least 3 months before the required date of publication. This list is provided as a service to readers; inclusion does not imply endorsement by the HBPD INT.Section editorShui-Ying LeiEmail: hbpdje@mail.hz.zj.cn     

Meetings and Courses

<正>Announcements for this section should be submitted in the correct format at least 3 months before the required date of publication. This list is provided as a service to readers; inclusion does not imply endorsement by the Hepatobiliary & Pancreatic Diseases International.     

Crohn’s and colitis in children and adolescents

Crohn’s disease and ulcerative colitis can be grouped as the inflammatory bowel diseases (IBD). These conditions have become increasingly common in recent years, including in children and young people. Although much is known about aspects of the pathogenesis of these diseases, the precise aetiology is not yet understood, and there remains no cure. Recent data has illustrated the importance of a number of genes-several of these are important in the onset of IBD in early life, including in infancy. Pain, diarrhoea and weight loss are typical symptoms of paediatric Crohn’s disease whereas bloody diarrhoea is more typical of colitis in children. However, atypical symptoms may occur in both conditions: these include isolated impairment of linear growth or presentation with extra-intestinal manifestations such as erythema nodosum. Growth and nutrition are commonly compromised at diagnosis in both Crohn’s disease and colitis. Consideration of possible IBD and completion of appropriate investigations are essential to ensure prompt diagnosis, thereby avoiding the consequences of diagnostic delay. Patterns of disease including location and progression of IBD in childhood differ substantially from adult-onset disease. Various treatment options are available for children and adolescents with IBD. Exclusive enteral nutrition plays a central role in the induction of remission of active Crohn’s disease. Medical and surgical therapies need to considered within the context of a growing and developing child. The overall management of these chronic conditions in children should include multi-disciplinary expertise, with focus upon maintaining control of gut inflammation, optimising nutrition, growth and quality of life, whilst preventing disease or treatment-related complications.     

Meetings and Courses

Announcements for this section should be submitted in the correct format at least 3 months before the required