Influenza | |
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Other names | Flu, the flu, Grippe |
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Influenza virus, magnified approximately 100,000 times | |
Specialty | Infectious disease |
Symptoms | Fever, runny nose, sore throat, muscle and joint pain, headache, coughing, feeling tired[1] |
Usual onset | One to four days after exposure[1] |
Duration | ~1 week[1] |
Causes | Influenza viruses[2] |
Prevention | Hand washing, influenza vaccine, surgical masks[1][3] |
Medication | Neuraminidase inhibitors such as oseltamivir[1] |
Frequency | 3–5 million severe cases per year[1] |
Deaths | Up to 650,000 respiratory deaths per year[1][4] |
Influenza, commonly known as "the flu", is an infectious disease caused by an influenza virus.[1] Symptoms can range from mild to severe and commonly include: high fever, runny nose, sore throat, muscle and joint pain, headache, coughing, and feeling tired.[5] These symptoms typically begin two days after exposure to the virus and most last less than a week, although the coughing may last for more than two weeks.[1][6] In children, there may be diarrhea and vomiting, but these are not common in adults.[7] Diarrhea and vomiting occur more commonly in gastroenteritis, which is an unrelated disease sometimes referred to as "stomach flu" or the "24-hour flu".[7] Complications of influenza may include viral pneumonia, secondary bacterial pneumonia, sinus infections, and worsening of previous health problems such as asthma or heart failure.[2][5]
Three of the four types of influenza viruses affect humans: Type A, Type B, and Type C.[2][8] Type D has not been known to infect humans, but is believed to have the potential to do so.[8][9] Usually, the virus is spread through the air from coughs or sneezes.[1] This is believed to occur mostly over relatively short distances.[10] It can also be spread by touching surfaces contaminated by the virus and then touching the eyes, nose, or mouth.[5][10][11] A person may be infectious to others both before and during the time they are showing symptoms.[5] The infection may be confirmed by testing the throat, sputum, or nose for the virus.[2] A number of rapid tests are available; however, people may still have the infection even if the results are negative.[2] A type of polymerase chain reaction that detects the virus's RNA is more accurate.[2]
Frequent hand washing reduces the risk of viral spread, as does wearing a surgical mask.[3][needs update] Yearly vaccinations against influenza are recommended by the World Health Organization (WHO) for those at high risk,[1] and by the Centers for Disease Control and Prevention (CDC) for those six months of age and older.[12] The vaccine is typically effective against three or four types of influenza and is usually well tolerated.[1] A vaccine made for one year may not be useful in the following year, since the virus evolves rapidly.[1] Antiviral medications such as the neuraminidase inhibitor oseltamivir, among others, have been used to treat influenza.[1] The benefit of antiviral medications in those who are otherwise healthy do not appear to be greater than their risks.[13] No benefit has been found in those with other health problems.[13][14]
Influenza spreads around the world in yearly outbreaks, resulting in about three to five million cases of severe illness and about 290,000 to 650,000 deaths.[1][4] About 20% of unvaccinated children and 10% of unvaccinated adults are infected each year, according to a 2018 study. [15] In the northern and southern parts of the world, outbreaks occur mainly in the winter, while around the equator, outbreaks may occur at any time of the year.[1] Death occurs mostly in high risk groups—the young, the old, and those with other health problems.[1] Larger outbreaks known as pandemics are less frequent.[2] In the 20th century, four major influenza pandemics occurred: the Spanish flu in 1918 (17–100 million deaths), the Asian flu in 1957 (1–4 million deaths), the Hong Kong flu in 1968 (1–4 million deaths) and the Russian flu in 1977 (700,000 deaths).[16][17][18][19][20] The World Health Organization declared an outbreak of a new type of influenza A/H1N1 to be a pandemic in June 2009.[21] Influenza may also affect other animals, including pigs, horses, and birds.[22]
Signs and symptoms
The time period between exposure to the virus and development of symptoms, called the incubation period, is 1–4 days, most commonly 1–2 days. Many infections, however, are asymptomatic.[26] The onset of symptoms is sudden, and initial symptoms are predominately non-specific, including fever, chills, headaches, muscle pain or aching, a feeling of discomfort, loss of appetite, lack of energy/fatigue, and confusion. These symptoms are usually accompanied by respiratory symptoms such as a dry cough, sore or dry throat, hoarse voice, and a stuffy or runny nose. Coughing is the most common symptom.[27] Gastrointestinal symptoms may also occur, including nausea, vomiting, diarrhea,[28] and gastroenteritis,[29] especially in children. The standard influenza symptoms typically last for 2–8 days.[30]
Symptomatic infections are usually mild and limited to the upper respiratory tract, but progression to pneumonia is relatively common. Pneumonia may be caused by the primary viral infection or by a secondary bacterial infection. Primary pneumonia is characterized by rapid progression of fever, cough, labored breathing, and low oxygen levels that cause bluish skin. It is especially common among those who have an underlying cardiovascular disease such as rheumatic heart disease. Secondary pneumonia typically has a period of improvement in symptoms for 1–3 weeks[31] followed by recurrent fever, sputum production, and fluid buildup in the lungs,[27] but can also occur just a few days after influenza symptoms appear.[31] About a third of primary pneumonia cases are followed by secondary pneumonia, which is most frequently caused by the bacteria Streptococcus pneumoniae and Staphylococcus aureus.[26][27]
Virology
Types of virus
Influenza viruses comprise four different species. Each of the four species is the sole member of its own genus, and the four influenza genera comprise four of the seven genera in the family Orthomyxoviridae. They are:[27][32]
- Influenza A virus (IAV), genus Alphainfluenzavirus
- Influenza B virus (IBV), genus Betainfluenzavirus
- Influenza C virus (ICV), genus Gammainfluenzavirus
- Influenza D virus (IDV), genus Deltainfluenzavirus
IAV is responsible for most cases of severe illness as well as seasonal epidemics and occasional pandemics. It infects people of all ages but tends to disproportionately cause severe illness in the elderly, the very young, and those who have chronic health issues. Birds are the primary reservoir of IAV, especially aquatic birds such as ducks, geese, shorebirds, and gulls,[33][34] but the virus also circulates among mammals, including pigs, horses, and marine mammals. IAV is classified into subtypes based on the viral proteins haemagglutinin (H) and neuraminidase (N).[35] As of 2019, 18 H subtypes and 11 N subtypes have been identified. Most potential combinations have been reported in birds, but H17-18 and N10-11 have only been found in bats. Only H subtypes H1-3 and N subtypes N1-2 are known to have circulated in humans,[35] the current IAV subtypes in circulation being H1N1 and H3N2.[36] IAVs can be classified more specifically to also include natural host species, geographical origin, year of isolation, and strain number, such as H1N1/A/duck/Alberta/35/76.[27][28]
IBV mainly infects humans but has been identified in seals, horses, dogs, and pigs.[35] IBV does not have subtypes like IAV but has two antigenically distinct lineages, termed the B/Victoria/2/1987-like and B/Yamagata/16/1988-like lineages,[27] or simply (B/)Victoria(-like) and (B/)Yamagata(-like).[35][36] Both lineages are in circulation in humans,[27] disproportionately affecting children.[28] IBVs contribute to seasonal epidemics alongside IAVs but have never been associated with a pandemic.[35]
ICV, like IBV, is primarily found in humans, though it also has been detected in pigs, feral dogs, dromedary camels, cattle, and dogs.[29][35] ICV infection primarily affects children and is usually asymptomatic[27][28] or has mild cold-like symptoms, though more severe symptoms such as gastroenteritis and pneumonia can occur.[29] Unlike IAV and IBV, ICV has not been a major focus of research pertaining to antiviral drugs, vaccines, and other measures against influenza.[35] ICV is subclassified into six genetic/antigenic lineages.[29][37]
IDV has been isolated from pigs and cattle, the latter being the natural reservoir. Infection has also been observed in humans, horses, dromedary camels, and small ruminants such as goats and sheep.[35][37] IDV is distantly related to ICV. While cattle workers have occasionally tested positive to prior IDV infection, it is not known to cause disease in humans.[27][28][29] ICV and IDV experience a slower rate of antigenic evolution than IAV and IBV. Because of this antigenically stability, relatively few novel lineages emerge.[37]
Genome and structure
![](https://web.archive.org/web/20210311044822im_/https://upload.wikimedia.org/wikipedia/commons/thumb/3/3b/3D_Influenza_virus.png/310px-3D_Influenza_virus.png)
Influenza viruses have a negative-sense, single-stranded RNA genome that is segmented. The negative sense of the genome means it can be used as a template to synthesize messenger RNA (mRNA).[26] IAV and IBV have eight genome segments that encode 10 major proteins. ICV and IDV have seven genome segments that encode nine major proteins.[29] Three segments encode three subunits of an RNA-dependent RNA polymerase (RdRp) complex: PB1, a transcriptase, PB2, which recognizes 5' caps, and PA (P3 for ICV and IDV), an endonuclease.[38] The matrix protein (M1) and membrane protein (M2) share a segment, as do the non-strucutral protein (NS1) and the nuclear export protein (NEP).[27] For IAV and IBV, hemagglutinin (HA) and neuraminidase (NA) are encoded on one segment each, whereas ICV and IDV encode a hemagglutinin-esterase fusion (HEF) protein on one segment that merges the functions of HA and NA. The final genome segment encodes the viral nucleoprotein (NP).[38] Influenza viruses also encode various accessory proteins, such as PB1-N40, PB1-F2, and PA-X that are expressed through alternative open reading frames[27][39] and which are important in host defense suppression, virulence, and pathogenicity.[40]
The virus particle, called a virion, is spherical, filamentous, or pleomorphic in shape and 80–120 nanometers (nm) in diameter.[38] The virion consists of each segment of the genome bound to nucleoproteins in separate ribonucleoprotein (RNP) complexes for each segment, all of which are surrounded by a lipid bilayer membrane called the viral envelope. There is a copy of the RdRp, all subunits included, bound to each RNP. The envelope is reinforced structurally by matrix proteins on the interior that enclose the RNPs,[41] and the envelope contains HA and NA (or HEF[37]) proteins extending outward from the exterior surface of the envelope. HA and HEF[37] proteins have a distinct "head" and "stalk" structure. M2 proteins form proton ion channels through the viral envelope that are required for viral entry and exit. IBVs contain a surface protein named NB that is anchored in the envelope, but its function is unknown.[27] NS1, NEP, PB1-F2, PA-X, and PB1-N40 are only expressed in host cells and are not found in the virion.[39]
Life cycle
The viral life cycle begins by binding to a target cell. Binding is mediated by the viral HA proteins on the surface of the evelope, which bind to cells that contain sialic acid receptors on the surface of the cell membrane.[27][33][41] For N1 subtypes with the "G147R" mutation and N2 subtypes, the NA protein can initiate entry. Prior to binding, NA proteins promote access to target cells by degrading mucous, which helps to remove extracellular decoy receptors that would impede access to target cells.[41] After binding, the virus is internalized into the cell by an endosome that contains the virion inside it. The endosome is acidified by cellular vATPase[39] to have lower pH, which triggers a conformational change in HA that allows fusion of the viral envelope with the endosomal membrane.[40] At the same time, hydrogen ions diffuse into the virion through M2 ion channels, disrupting internal protein-protein interactions to release RNPs into the host cell's cytosol. The M1 protein shell surrounding RNPs is degraded, fully uncoating RNPs in the cytosol.[39][41]
RNPs are then imported into the nucleus with the help of viral localization signals. There, the viral RNA polymerase transcribes mRNA using the genomic negative-sense strand as a template. The polymerase snatches 5' caps for viral mRNA from cellular RNA to prime mRNA synthesis and the 3'-end of mRNA is polyadenylated at the end of transcription.[38] Once viral mRNA is transcribed, it is exported out of the nucleus and translated by host ribosomes in a cap-dependent manner to synthesize viral proteins.[39] RdRp also synthesizes complementary positive-sense strands of the viral genome in a complementary RNP complex which are then used as templates by viral polymerases to synthesize copies of the negative-sense genome.[27][41] During these processes, RdRps of avian influenza viruses (AIVs) function optimally at a higher temperature than mammalian influenza viruses.[30]
Newly synthesized viral polymerase subunits and NP proteins are imported to the nucleus to further increase the rate of viral replication and form RNPs.[38] HA, NA, and M2 proteins are trafficked with the aid of M1 and NEP proteins[40] to the cell membrane through the Golgi apparatus[38] and inserted into the cell's membrane. Viral non-structural proteins including NS1, PB1-F2, and PA-X regulate host cellular processes to disable antiviral responses.[27][40][41] PB1-F2 aso interacts with PB1 to keep polymerases in the nucleus longer.[34] M1 and NEP proteins localize to the nucleus during the later stages of infection, bind to viral RNPs and mediate their export to the cytoplasm where they migrate to the cell membrane with the aid of recycled endosomes and are bundled into the segments of the genome.[27][41]
Progenic viruses leave the cell by budding from the cell membrane, which is initiated by the accumulation of M1 proteins at the cytoplasmic side of the membrane. The viral genome is incorporated inside a viral envelope derived from portions of the cell membrane that have HA, NA, and M2 proteins. At the end of budding, HA proteins remain attached to cellular sialic acid until they are cleaved by the sialidase activity of NA proteins. The virion is then released from the cell. The sialidase activity of NA also cleaves any sialic acid residues from the viral surface, which helps prevent newly assembled viruses from aggregating near the cell surface and improving infectivity.[27][41] Similar to other aspects of influenza replication, optimal NA activity is temperature- and pH-dependent.[30] Ultimately, presence of large quantities of viral RNA in the cell triggers apoptosis, i.e. programmed cell death, which is initiated by cellular factors to restrict viral replication.[39]
Antigenic drift and shift
Two key processes that influenza viruses evolve through are antigenic drift and antigenic shift. Antigenic drift is when an influenza virus's antigens change due to the gradual accumulation of mutations in the antigen's (HA or NA) gene.[33] This can occur in response to evolutionary pressure exerted by the host immune response. Antigenic drift is especially common for the HA protein, in which just a few amino acid changes in the head region can constitute antigenic drift.[36][37] The result is the production of novel strains that can evade pre-existing antibody-mediated immunity.[27][28] Antigenic drift occurs in all influenza species but is slower in B than A and slowest in C and D.[37] Antigenic drift is a major cause of seasonal influenza,[42] and requires that flu vaccines be updated annually. HA is the main component of inactivated vaccines, so surveillance monitors antigenic drift of this antigen among circulating strains. Antigenic evolution of influenza viruses of humans appears to be faster than influenza viruses in swine and equines. In wild birds, within-subtype antigenic variation appears to be limited but has been observed in poultry.[27][28]
Antigenic shift is a sudden, drastic change in an influenza virus's antigen, usually HA. During antigenic shift, antigenically different strains that infect the same cell can reassort genome segments with each other, producing hybrid progeny. Since all influenza viruses have segmented genomes, all are capable of reassortment.[29][37] Antigenic shift, however, only occurs among influenza viruses of the same genus[38] and most commonly occurs among IAVs. In particular, reassortment is very common in AIVs, creating a large diversity of influenza viruses in birds, but is uncommon in human, equine, and canine lineages.[43] Pigs, bats, and quails have receptors for both mammalian and avian IAVs, so they are potential "mixing vessels" for reassortment.[35] If an animal strain reassorts with a human strain,[36] then a novel strain can emerge that is capable of human-to-human transmission. This has caused pandemics, but only a limited number have occurred, so it is difficult to predict when the next will happen.[27][28]
Mechanism
Transmission
When an infected person sneezes or coughs more than half a million virus particles can be spread to those close by.[44] In otherwise healthy adults, influenza virus shedding (the time during which a person might be infectious to another person) increases sharply one-half to one day after infection, peaks on day 2 and persists for an average total duration of 5 days—but can persist as long as 9 days.[6][45] In those who develop symptoms from experimental infection (only 67% of healthy experimentally infected individuals), symptoms and viral shedding show a similar pattern, but with viral shedding preceding illness by one day.[45] Children are much more infectious than adults and shed virus from just before they develop symptoms until two weeks after infection.[46] In immunocompromised people, viral shedding can continue for longer than two weeks.[47]
Influenza can be spread in three main ways: by direct transmission (when an infected person sneezes mucus directly into the eyes, nose or mouth of another person); the airborne route (when someone inhales the aerosols produced by an infected person coughing, sneezing or spitting) and through hand-to-eye, hand-to-nose, or hand-to-mouth transmission, either from contaminated surfaces or from direct personal contact such as a handshake.[48][49] The relative importance of these three modes of transmission is unclear, and they may all contribute to the spread of the virus.[10] In the airborne route, the droplets that are small enough for people to inhale are 0.5 to 5 μm in diameter and inhaling just one droplet might be enough to cause an infection.[48] Although a single sneeze releases up to 40,000 droplets,[50] most of these droplets are quite large and will quickly settle out of the air.[48] How long influenza survives in airborne droplets seems to be influenced by the levels of humidity and UV radiation, with low humidity and a lack of sunlight in winter aiding its survival;[48] ideal conditions can allow it to live for an hour in the atmosphere.[51]
As the influenza virus can persist outside of the body, it can also be transmitted by contaminated surfaces such as banknotes,[52] doorknobs, light switches and other household items.[53] The length of time the virus will persist on a surface varies, with the virus surviving for one to two days on hard, non-porous surfaces such as plastic or metal, for about fifteen minutes on dry paper tissues, and only five minutes on skin.[54] However, if the virus is present in mucus, this can protect it for longer periods (up to 17 days on banknotes).[48][52] Avian influenza viruses can survive indefinitely when frozen.[55] They are inactivated by heating to 56 °C (133 °F) for a minimum of 60 minutes, as well as by acids (at pH<2).[55]
Pathophysiology
![](https://web.archive.org/web/20210311044822im_/https://upload.wikimedia.org/wikipedia/commons/thumb/b/b0/H1N1_versus_H5N1_pathology.png/310px-H1N1_versus_H5N1_pathology.png)
The mechanisms by which influenza infection causes symptoms in humans have been studied intensively. One of the mechanisms is believed to be the inhibition of adrenocorticotropic hormone (ACTH) resulting in lowered cortisol levels.[56] Knowing which genes are carried by a particular strain can help predict how well it will infect humans and how severe this infection will be (that is, predict the strain's pathophysiology).[57][58]
For instance, part of the process that allows influenza viruses to invade cells is the cleavage of the viral hemagglutinin protein by any one of several human proteases.[59] In mild and avirulent viruses, the structure of the hemagglutinin means that it can only be cleaved by proteases found in the throat and lungs, so these viruses cannot infect other tissues. However, in highly virulent strains, such as H5N1, the hemagglutinin can be cleaved by a wide variety of proteases, allowing the virus to spread throughout the body.[58]
The viral hemagglutinin protein is responsible for determining both which species a strain can infect and where in the human respiratory tract a strain of influenza will bind.[60] Strains that are easily transmitted between people have hemagglutinin proteins that bind to receptors in the upper part of the respiratory tract, such as in the nose, throat and mouth. In contrast, the highly lethal H5N1 strain binds to receptors that are mostly found deep in the lungs.[61] This difference in the site of infection may be part of the reason why the H5N1 strain causes severe viral pneumonia in the lungs, but is not easily transmitted by people coughing and sneezing.[62][63]
Common symptoms of the flu such as fever, headaches, and fatigue are the result of the huge amounts of proinflammatory cytokines and chemokines (such as interferon or tumor necrosis factor) produced from influenza-infected cells.[64][65] In contrast to the rhinovirus that causes the common cold, influenza does cause tissue damage, so symptoms are not entirely due to the inflammatory response.[66] This massive immune response might produce a life-threatening cytokine storm. This effect has been proposed to be the cause of the unusual lethality of both the H5N1 avian influenza,[67] and the 1918 pandemic strain.[68][69] However, another possibility is that these large amounts of cytokines are just a result of the massive levels of viral replication produced by these strains, and the immune response does not itself contribute to the disease.[70] Influenza appears to trigger programmed cell death (apoptosis).[71]
Prevention
Vaccination
Annual vaccination is the primary and most effective way to prevent influenza and influenza-associated complications, especially for high-risk groups.[26][27][72] Vaccines against the flu are trivalent or quadrivalent, providing protection against an H1N1 strain, an H3N2 strain, and one or two IBV strains corresponding to the two IBV lineages.[26][36] Two types of vaccines are in use: inactivated vaccines that contain "killed" (i.e. inactivated) viruses and live attenuated influenza vaccines (LAIVs) that contain weakened viruses.[27] There are three types of inactivated vaccines: whole virus, split virus, in which the virus is disrupted by a detergent, and subunit, which only contains the viral antigens HA and NA.[73] Most flu vaccines are inactivated and administered via intramuscular injection. LAIVs are sprayed into the nasal cavity.[27]
Vaccination recommendations vary from country to country. It some countries, it is recommended that all people above a certain age, such as 6 months,[72] be vaccinated, whereas in others it is recommended for people who belong to at-risk groups, such as pregnant women, young children (excluding newborns), the elderly, people with chronic medical conditions, health care workers,[27] people who come into contact with high-risk people, and people who transmit the virus easily.[28] Young infants cannot receive flu vaccines for safety reasons, but they can inherit passive immunity from their mother if inactivated vaccines are administered to the mother during pregnancy.[74] Influenza vaccination also helps to reduce the probability of reassortment.[30]
The effectiveness of seasonal flu vaccines varies significantly, with an estimated average efficacy of 50–60%,[36] depending on vaccine strain, age, prior immunity, and immune function, so vaccinated people can still contract influenza.[72] The effectiveness of flu vaccines is considered to be suboptimal, particularly among the elderly,[27] but vaccination is still beneficial in reducing the mortality rate and hospitalization rate due to influenza as well as duration of hospitalization.[72][75] Vaccination of school-age children has shown to provide indirect protection for other age groups. LAIVs are recommended for children based on superior efficacy, especially for children under 6, and greater immunity against non-vaccine strains when compared to inactivated vaccines.[28][74]
Common side effects of vaccination include local injection-site reactions and cold-like symptoms. Fever, malaise, and myalgia are less common. Flu vaccines are contraindicated for people who have experienced a severe allergic reaction in response to a flu vaccine or to any component of the vaccine. LAIVs are not given to children or adolescents with severe immunodeficiency or to those who are using salicylate treatments because of the risk of developing Reye syndrome.[28] LAIVs are also not recommended for children under the age of 2,[74] pregnant women, and adults with immunosuppression. Inactivated flu vaccines cannot cause influenza and are regarded as safe during pregnancy.[28]
In general, influenza vaccines are only effective if there is an antigenic match between vaccine strains and circulating strains.[26][36] Additionally, most commercially available flu vaccines are manufactured by propagation of influenza viruses in embryonated chicken eggs, taking 6–8 months.[36] Flu seasons are different in the northern and southern hemisphere, so the WHO meets twice a year, one for each hemisphere, to discuss which strains should be included in flu vaccines based on observation from HA inhibition assays.[26][41] Other manufacturing methods include an MDCK cell culture-based inactivated vaccine and a recombinant subunit vaccine manufactured from baculovirus overexpression in insect cells.[36][76]
Antiviral chemoprophylaxis
Influenza can be prevented or reduced in severity by post-exposure prophylaxis with the antiviral drugs oseltamivir, which can be taken orally by those at least three months old, and zanamivir, which can be inhaled by those above seven years of age. Chemoprophylaxis is most useful for individuals at high-risk of developing complications and those who cannot receive the flu vaccine due to contraindiciations or lack of effectiveness.[26] Post-exposure chemoprophylaxis is only recommended if oseltamivir is taken within 48 hours of contact with a confirmed or suspected influenza case and zanmivir within 36 hours.[26][28] It is recommended that it be offerred to people who have yet to receive a vaccine for the current flu season, who have been vaccinated less than two week since contact, where there is a significant mismatch between vaccine and circulating strains, or during an outbreak in a closed setting regardless of vaccination history.[28]
Infection control
Hand hygiene is imoprtant in reducing the spread of influenza. This includes measures such as frequent hand washing with soap and water, using alcohol-based hand sanitizers, and not touching one's eyes, nose, and mouth with one's hands. Couvering one's nose and mouth when coughing or sneezing is important.[77] Other methods to limit influenza transmission include staying home when sick,[27] avoiding contact with others until one day after symptoms end,[28] and disinfecting surfaces likely to be contaminated by the virus, such as doorknobs.[27] Health education through media and posters is often used to remind people of the aforementioned etiquette and hygiene.[26]
There is uncertainty about the use of masks since research thus far has not shown a significant reduction in seasonal influenza with mask usage. Likewise, the effectiveness of screening at points of entry into countries is not well researched.[77] Social distancing measures such as school closures, avoiding contact with infected people via isolation or quarantine, and limiting mass gatherings may reduce transmission,[27][77] but these measures are often expensive, unpopular, and difficult to implement. Consequently, the commonly recommended methods of infection control are respiratory etiquette, hand hygiene, and mask wearing, which are inexpensive and easy to perform. Pharmaceutical measures are effective but may not be available in the early stages of an outbreak.[78]
In health care settings, infected individuals may be cohorted or assigned to individual rooms. Protective clothing such as masks, gloves, and gowns is recommended when coming into contact with infected individuals if there is a risk of exposure to infected bodily fluids. Keeping patients in negative pressure rooms and avoiding aerosol-producing activities may help,[26] but special air handling are ventilation systems are not considered necessary to prevent the spread of influenza in the air.[79] In residential homes, new admissions may need to be closed until the spread of influenza is controlled. When discharging patients to care homes, it is important to take care if there is a known influenza outbreak.[28]
Since influenza viruses circulate in animals such as birds and pigs, prevention of transmission from these animals is important. Water treatment, indoor raising of animals, quarantining sick animals, vaccination, and biosecurity are the primary measures used. Placing poultry houses and piggeries on high ground away from high-density farms, backyard farms, live poultry markets, and bodies of water helps to minimize contact with wild birds.[27] Closure of live poultry markets appears to the most effective measure[33] and has shown to be effective at controlling the spread of H5N1, H7N9, and H9N2.[34] Other biosecurity measures include cleaning and disinfecting facilities and vehicles, banning visits to poultry farms, not bringing birds intended for slaughter back to farms,[80] changing clothes, disinfecting foot baths, and treating food and water.[27]
If live poultry markets are not closed, then "clean days" when unsold poultry is removed and facilities are disinfected and "no carry-over" policies to eliminate infectious material before new poultry arrive can be used to reduce the spread of influenza viruses. If a novel influenza viruses has breached the aforementioned biosecurity measures, then rapid detection to stamp it out via quarantining, decontamination, and culling may be necessary to prevent the virus from becoming endemic.[27] Vaccines exist for avian H5, H7, and H9 subtypes that are used in some countries.[33] In China, for example, vaccination of domestic birds against H7N9 successfully limited its spread, indicating that vaccination may be an effective strategy[43] if used in combination with other measures to limit transmission.[27] In pigs and horses, management of influenza is dependent on vaccination with biosecurity.[27]
Diagnosis
Diagnosis based on symptoms is fairly accurate in otherwise healthy people during seasonal epidemics and should be suspected in cases of pneumonia, ARDS, sepsis, or if encephalitis, myocarditis, and rhabdomyolysis occur.[31] Because influenza is similar to other viral respiratory tract illnesses, laboratory diagnosis is necessary for confirmation. Common ways of collecting samples for testing include nasal and throat swabs.[27] Samples may be taken from the lower respiratory tract if infection has cleared the upper but not lower respiratory tract. Influenza testing is recommended for anyone hospitalized with symptoms resembling influenza during flu season or who is connected to an influenza case. For severe cases, earlier diagnosis improves patient outcome.[72] Diagnostic methods that can identify influenza include viral cultures, antibody- and antigen-detecting tests, and nucleic acid-based tests.[81]
Viruses can be grown in a culture of mammalian cells or embryonated eggs for 3–10 days to monitor cytopathic effect. Final confirmation can then be done via antibody staining, hemadsorption using erythrocytes, or immunofluorescence microscopy. Shell vial cultures, which can identify infection via immunostaining before a cytopathic effect appears, are more sensitive than traditional cultures with results in 1–3 days.[27][72][81] Cultures can be used to charactize novel viruses, observe sensitivity to antiviral drugs, and monitor antigenic drift, but they are relatively slow and require specialized skills and equipment.[27]
Serological assays can be used to detect an antibody response to influenza after natural infection or vaccination. Common serological assays include hemagglutination inhibition assays that detect HA-specific antibodies, virus neutralization assays that check whether antibodies have neutralized the virus, and enzyme-linked immunoabsorbant assays. These methods tend to be relatively inexpensive and fast but are less reliable than nucleic-acid based tests.[27][81]
Direct fluorescent or immunofluorescent antibody (DFA/IFA) tests involve staining respiratory epithelial cells in samples with fluorescently-labeled influenza-specific antibodies, followed by examination under a fluorescent microscope. They can differentiate between IAV and IBV but can't subtype A.[81] Rapid influenza diagnostic tests (RIDTs) are a simple way of obtaining assay results, are low cost, and produce results quickly, at less than 30 minutes, so they are commonly used, but they can't distinguish between IAV and IBV or between IAV subtypes and are not as sensitive as nucleic-acid based tests.[27][81]
Nucleic acid-based tests (NATs) amplify and detect viral nucleic acid. Most of these tests take a few hours,[81] but rapid molecular assays are as fast as RIDTs.[72] Among NATs, reverse transcription polymerase chain reaction is the most traditional and considered the gold standard for diagnosing influenza[81] because it is fast and can subtype IAV, but it is relatively expensive and more prone to false-positives than cultures.[27] Other NATs that have been used include loop-mediated isothermal amplification-based assay, simple amplification-based assay, and nucleic acid sequence-based amplification. Nucleic acid sequencing methods can identify infection by obtaining the nucleic acid sequence of viral samples to identify the virus and antiviral drug resistance. The traditional method is Sanger sequencing, but it has been largely replaced by next-generation methods that have greater sequencing speed and throughput.[81]
Treatment
Treatment of influenza in cases of mild or moderate illness is supportive and includes anti-fever medications such as acetaminophen and ibuprofen,[82] adequate fluid intake to avoid dehydration, and resting at home.[28] Cough drops and throat sprays may be beneficial for sore throat. It is recommended to avoid alcohol and tobacco use while sick with the flu.[82] Aspirin should not be used to treat influenza in children due to an elevated risk of developing Reye syndrome.[83] Corticosteroids likewise are not recommended except when treating septic shock or an underyling medical condition, such as chronic obstructive pulmonary disease or asthma exacerbation, since they are associated with increased mortality.[72] If a secondary bacterial infection occurs, then treatment with antibiotics may be necessary.[28]
Antivirals
Drug | Route of administration | Approved age of use |
---|---|---|
Oseltamivir | Oral | At least two weeks old |
Zanamivir | Inhalation | At least five years old |
Peramivir | Intravenous injection | At least 18 years old |
Laninamivir | Inhalation[27] | 40 milligrams (mg) dose for people at least 10 years old, 20 mg for those under 10[84] |
Baloxavir marboxil | Oral[79] | At least 12 years old[72] |
Antiviral drugs are primarily used to treat severely ill patients, especially those with compromised immune systems. Antivirals are most effective when started in the first 48 hours after symptoms appear. Later administration may still be beneficial for those who have underlying immune defects, those with more severe symptoms, or those who have a higher risk of developing complications if these individuals are still shedding the virus. Antiviral treatment is also recommended if a person is hospitalized with suspected influenza instead of waiting for test results to return and if symptoms are worsening.[27][72] Most antiviral drugs against influenza fall into two categories: neuraminidase (NA) inhibitors and M2 inhibitors.[30] Baloxavir marboxil is a notable exception, which targets the endonuclease activity of the viral RNA polymerase and can be used as an alternative to NA and M2 inhibitors for IAV and IBV.[26][33][79]
NA inhibitors target the enzymatic activity of NA receptors, mimicking the binding of sialic acid in the active site of NA on IAV and IBV virions[27] so that viral release from infected cells and the rate of viral replication are impaired.[28] NA inhibitors include oseltamivir, which is consumed orally in a prodrug form and converted to its active form in the liver, and zanamivir, which is a powder that is inhaled nasally. Oseltamivir and zanamivir are effective for prophylaxis and post-exposure prophylaxis, and research overall indicates that NA inhibitors are effective at reducing rates of complications, hospitalization, and mortality[27] and the duration of illness.[30][72][79] Additionally, the earlier NA inhibitors are provided, the better the outcome,[79] though late administration can still be beneficial in severe cases.[27][72] Other NA inhibitors include laninamivir[27] and peramivir, the latter of which can be used as an alternative to oseltamivir for people who cannot tolerate or absorb it.[72]
The adamantanes amantadine and rimantadine are orally administered drugs that block the influenza virus's M2 ion channel,[27] preventing viral uncoating.[79] These drugs are only functional against IAV[72] but are no longer recommended for use because of widespread resistence to them among IAVs.[79] Adamantane resistence first emerged in H3N2 in 2003, becoming worldwide by 2008. Oseltamivir resistance is no longer widespread because the 2009 pandemic H1N1 strain (H1N1 pdm09), which is resistant to adamantanes, seemingly replaced resistant strains in circulation. Since the 2009 pandemic, oseltamivir resistance has mainly been observed in patients undergoing therapy,[27] especially the immunocompromised and young children.[79] Oseltamivir resistance is usually reported in H1N1, but has been reported in H3N2 and IBVs less commonly.[27] Because of this, oseltamivir is recommended as the first drug of choice for immunocompetent people, whereas for the immunocompromised, oseltamivir is recommended against H3N2 and IBV and zanamivir against H1N1 pdm09. Zanamivir resistance is observed less frequently, and resistance to peramivir and baloxavir marboxil is possible.[79]
Prognosis
In healthy individuals, influenza infection is usually self-limiting and rarely fatal.[26][28] Symptoms usually last for 2–8 days.[30] Influenza can cause people to miss work or school, and it is associated with decreased job performance and, in older adults, reduced independence. Fatigue and malaise may last for several weeks after recovery, and healthy adults may experience pulmonary abnormalities that can take several weeks to resolve. Complications and mortality primarily occur in high-risk populations and those who are hospitalized. Severe disease and mortality are usually attributable to pneumonia from the primary viral infection or a secondary bacterial infection,[27][28] which can progress to acute respiratory disress syndrome (ARDS).[30]
Other respiratory complications that may occur include sinusitis, bronchitis, bronchiolitis, excess fluid buildup in the lings, and exercerbation of chronic bronchitis and asthma. Middle ear infection and croup may occur, most commonly in children.[26][27] Secondary S. aureus infection has been observed, primarily in children, to cause toxic shock syndrome after influenza, with hypotension, fever, and reddening and peeling of the skin.[27] Complications affecting the cardiovascular system are rare and include pericarditis, fulminant myocarditis with a fast, slow, or irregular heartbeat, and exacerbation of pre-existing cardiovascular disease.[26][28] Inflammation or swelling of muscles accompanied by muscle tissue breaking down occurs rarely, usually in children, which presents as extreme tenderness and muscle pain in the legs and a reluctance to walk for 2–3 days.[27][28][31]
Influenza can affect pregnancy, including causing smaller neonatal size, increased risk of premature birth, and an increased risk of child death shortly before or after birth.[28] Neurological complications have been associated with influenza on rare ocassions, including aseptic meningitis, encephalitis, disseminated encephalomyelitis, transverse myelitis, and Guillain–Barré syndrome.[31] Additionally, febrile seizures and Reye syndrome can occur, most commonly in children.[27][28] Influenza-associated encephalopathy can occur directly from central nervous system infection from the presence of the virus in blood and presents as suddent onset of fever with convulsions, followed by rapid progression to coma.[26] An atypical form of encephalitis called encephalitis lethargica, characterized by headache, drowsiness, and coma, may rarely occur sometime after infection.[27] In survivors of influenza-associated encephalopathy, neurological defects may occur.[26] Primarily in children, in severe cases the immune system may rarely dramatically overproduce white blood cells that release cytokines, causing severe inflammation.[26]
People who are at least 65 years of age,[28] due to a weakened immune system from aging or a chronic illness, are a high-risk group for developing complications, as are children less than one year of age and children who have not been previously exposed to influenza viruses multiple times. Pregnant women are at an elevated risk, which increases by trimester[27] and lasts up to two weeks after childbirth.[28][72] Obesity, in particular a body mass index greater than 35–40, is associated with greater amounts of viral replication, increased severity of secondary bacterial infection, and reduced vaccination efficacy. People who have underlying health conditions are also considered at-risk, including those who have congenital or chronic heart problems or lung (e.g. asthma), kidney, liver, blood, neurological, or metabolic (e.g. diabetes) disorders,[26][27][28] as are people who are immunocompromised from chemotherapy, asplenia, prolonged steroid treatment, splenic dysfunction, or HIV infection.[28] Current or past tobacco use also places a person at risk.[72] The role of genetics in influenza is not well researched,[27] but it may be a factor in influenza mortality.[30]
Epidemiology
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Influenza is typically characterized by seasonal epidemics and sporadic pandemics. Most of the burden of influenza is a result of flu seasons caused by IAV and IBV. Among IAV subtypes, H1N1 and H3N2 currently circulate in humans and are responsible for seasonal influenza. Cases disproportionately occur in children, but most severe causes are among the elderly, the very young,[27] and the immunocompromised.[79] In a typical year, influenza viruses infect 5–15% of the global population,[41][81] causing 3–5 million cases of severe illness annually[27][36] and accounting for 250,000–650,000 deaths each year.[41][79][note 1] 5–10% of adults and 20–30% of children contract infleunza each year.[35] The reported number of influenza cases is usually much lower than the actual number of cases.[27][74]
During seasonal epidemics, it is estimated that about 80% of otherwise healthy people who have a cough or sore throat have the flu.[27] Approximately 30–40% of people hospitalized for influenza develop pneumonia, and about 5% of all severe pneumonia cases in hospitals are due to influenza, which is also the most common cause of ARDS in adults. In children, influenza is one of the two most common causes of ARDS, the other being the respiratory syncytial virus.[31] About 3–5% of children each year develop otitis media due to influenza.[26] Adults who develop organ failure from influenza and children who have PIM scores and acute renal failure have higher rates of mortality.[31] During seasonal influenza, mortality is concentrated in the very young and the elderly, whereas during flu pandemics, young adults are often affected at a high rate.[30]
In temperate regions, the number of influenza cases varies from season to season. Low humidity, low temperature, and minor changes in virus proteins caused by antigenic drift result in annual epidemics that peak during the winter season. In the northern hemisphere, this is from October to May (more narrowly December to April[30]), and in the southern hemisphere, this is from May to October (more narrowly June to September[30]). There are therefore two distinct influenza seasons every year in temperate regions, one in the northern hemisphere and one in the southern hemisphere.[27][28][36] In tropical and subtropical regions, seasonality is more complex and appears to be affected by various climatic factors such as minimum temperature, hours of sunshine, maximum rainfall, and high humidity.[27][86] Influenza may therefore occur year-round in these regions.[30] Influenza epidemics in modern times have the tendency to start in the eastern or southern hemisphere,[86] with Asia being a key reservoir of influenza viruses.[30]
IAV and IBV co-circulate, so the two have the same patterns of transmission.[27] The seasonality of ICV, however, is poorly understood. ICV infection is most common in children under the age of 2, and by adulthood most people have been exposed to it. ICV-associated hospitalization most commonly occurs in children under the age of 3 and is frequently accompanied by co-infection with another virus or a bacterium, which may increase the severity of disease. When considering all hospitalizations for respiratory illness among young children, ICV appears to account for only a small percentage of such cases. Large outbreaks of ICV infection can occur, so incidence varies significantly.[29]
Outbreaks of influenza caused by novel influenza viruses are common.[38] Depending on the level of pre-existing immunity in the population, novel influenza viruses can spready rapidly and cause pandemics with millions of deaths. These pandemics, in contrast to seasonal influenza, are caused by antigenic shifts involving animal influenza viruses. To date, all known flu pandemics have been caused by IAVs, and they follow the same pattern of spreading from an origin point to the rest of the world over the course of multiple waves in a year.[27][28][72] Pandemic strains tend to be associated with higher rates of pneumonia in otherwise healthy individuals.[31] Generally after each influenza pandemic, the pandemic strain continues to circulate as the cause of seasonal influenza, replacing prior strains.[27] From 1700 to 1889, influenza pandemics occurred about once every 50–60 years. Since then, pandemics have occurred about once every 10–50 years, so they may be getting more frequent over time.[86]
History
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It is impossible to know when an influenza virus first infected humans or when the first influenza pandemic occurred.[88] Possibly the first influenza epidemic occurred around 6,000 BC in China,[89] and possible descriptions of influenza exist in Greek writings from the 5th century BC.[86][90] Influenza may have been circulating as an epidemic disease since at least the 9th century AD. A respiratory disease known as febris Italica (Italian fever) afflicted Charlemagne's army as it moved throughout Europe in 876–877. In both 1173–1174 and 1387, epidemics occurred across Europe that were named "influenza". Whether these epidemics and others were caused by influenza is unclear since there was no consistent naming pattern for epidemic respiratory diseases at that time, and "influenza" didn't become completely attached to respiratory disease until centuries later.[91] Influenza may have been brought to the Americas as early as 1493, when an epidemic disease resembling influenza killed most of the population of the Antilles.[92][93]
The first convincing record of an influenza pandemic was chronicled in 1510, which began in East Asia before spreading to North Africa and then Europe.[88] Following the pandemic, seasonal influenza occurred, with subsequent pandemics in 1557 and 1580.[91] The flu pandemic in 1557 was potentially the first time influenza was connected to miscarriage and death of pregnant women.[94] The 1580 flu pandemic originated in Asia during summer, spread to Africa, then Europe, and finally America.[86] By the end of the 16th century, influenza was likely beginning to become understood as a specific, recognizable disease with epidemic and endemic forms.[91] In 1648, it was discovered that horses also experience influenza, showing that the disease also occurred in animals.[88]
Influenza data after 1700 is more informative, so it is easier to identify flu pandemics after this point, each of which incrementally increased understanding of influenza.[95] The first flu pandemic of the 18th century started in 1729 in Russia in spring, spreading worldwide over the course of three years with distinct waves, the later ones being more lethal. The second flu pandemic of the 18th century was in 1781–1782, starting in China in autumn.[86] From this pandemic, influenza became associated with sudden outbreaks of febrile illness.[95] The next flu pandemic was from 1830 to 1833, beginning in China in winter. This pandemic had a high attack rate, but the mortality rate was low.[42][86]
A minor influenza pandemic occurred from 1847 to 1851 at the same time as the third cholera pandemic and was the first flu pandemic to occur with vital statistics being recorded, so influenza mortality was clearly recorded for the first time.[95] Highly pathogenic avian influenza was recognized in 1878[95] and was soon linked to transmission to humans.[88] By the time of the 1889 pandemic, which may have been caused by an H2N2 strain,[96] the flu had become an easily recognizable disease.[88]
Initially, the microbial agent responsible for influenza was incorrently identified in 1892 by R. F. J. Pfeiffer as the bacteria species Haemophilus influenzae, which retains "influenza" in its name.[88][95] In the following years, the field of virology began to form as viruses were identified as the cause of many diseases. From 1901 to 1903, Italian and Austrian researchers were able to show that avian influenza, then called "fowl plague",[43] was caused by a microscopic agent smaller than bacteria by using filters with pores too small for bacteria to pass through. The fundamental differences between viruses and bacteria, however, were not yet fully understood.[95]
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From 1918 to 1920, the Spanish flu pandemic became the most devastating influenza pandemic and one of the deadlist pandemics in history. The pandemic, probably caused by H1N1, likely began in the USA before spreading worldwide by soldiers during and after the First World War. The initial wave in the first half of 1918 was relatively minor and resembled past flu pandemics, but the second wave later that year had a much higher mortality rate,[86] accounting for most deaths. A third wave with lower mortality occurred in many places a few months after the second.[42] By the end of 1920, it is estimated that about a third[30] to half of all people in the world had been infected, with tens of millions of deaths, disproportionately young adults.[86] During the 1918 pandemic, the respiratory route of transmission was clearly identified[42] and influenza was shown to be caused by a "filter passer", not a bacterium, but there remained a lack of agreement about influenza's cause for another decade and research on influenza declined.[95] After the pandemic, H1N1 circulated in humans in seasonal form[27] up until the next pandemic in 1956.[95]
In 1931, Richard Shope published three papers identifying a virus as the cause of swine influenza, a then newly recognized disease among pigs that was first characterized during the second wave of the 1918 pandemic.[94][95] Shope's research reinvigorated research on human influenza, and many advances in virology, serology, immunology, experimental animal models, vaccinology, and immunotherapy have since arisen from influenza research.[95] Just two years after influenza viruses were discovered, in 1933, IAV was identified as the agent responsible for human influenza.[94][98] Subtypes of IAV were discovered throughout the 1930s,[95] and IBV was discovered in 1940.[35]
During the Second World War, the US government worked on developing inactivated vaccines for influenza, resulting in the first influenza vaccine being licensed in 1945 in the United States.[27] ICV was discovered two years later in 1947.[35] In 1955, avian influenza was confirmed to be caused by IAV.[43] Four influenza pandemics have occurred since WWII, each less severe than the 1918 pandemic. The first of these was the Asian flu from 1957 to 1958, caused by an H2N2 strain[27][78] and beginning in China's Yunnan province. The number of deaths probably exceeded one million, mostly among the very young and very old.[86] Notably, the 1957 pandemic was the first flu pandemic to occur in the presence of a global surveillance system and laboratories able to study the novel influenza virus.[42] After the pandemic, H2N2 was the IAV subtype responsible for seasonal influenza.[27] The first antiviral drug against influenza, amantadine, was approved for use in 1966, with additional antiviral drugs being used since the 1990s.[79]
In 1968, H3N2 was introduced into humans as a result of a reassortment between an avian H3N2 strain and an H2N2 strain that was circulating in humans. The novel H3N2 strain first emerged in Hong Kong and spread worldwide, causing the Hong Kong flu pandemic, which resulted in 500,000–2,000,000 deaths. This was the first pandemic to spread significantly by air travel.[41][42] H2N2 and H3N2 co-circulated after the pandemic until 1971 when H2N2 waned in prevalence and was completely replaced by H3N2.[41] In 1977, H1N1 reemerged in humans, possibly after it was released from a freezer in a laboratory accident, and caused a pseudo-pandemic.[42][95] Whether the 1977 "pandemic" deserves to be included in the natural history of flu pandemics is debatable.[86] This H1N1 strain was antigenically similar to the H1N1 strains that circulated prior to 1957. Since 1977, both H1N1 and H3N2 have circulated in humans as part of seasonal influenza.[27] In 1980, the current classification system used to subtype influenza viruses was introduced.[99]
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At some point, IBV diverged into two lineages, named the B/Victoria-like and B/Yamagata-like lineages, both of which have been circulating in humans since 1983.[35] In 1996, HPAI H5N1 was detected in Guangdong, China[43] and a year later emerged in poultry in Hong Kong, gradually spreading worldwide from there. A small H5N1 outbreak in humans in Hong Kong occurred then,[59] and sporadic human cases have occurrence since 1997, carrying a high case fatality rate.[33][81] The most recent pandemic was the 2009 swine flu pandemic, which originated in Mexico and resulted in hundreds of thousands of deaths.[42] It was caused by a novel H1N1 strain that was a reassortment of human, swine, and avian influenza viruses.[34][79] The 2009 pandemic had the effect of replacing prior H1N1 strains in circulation with the novel strain but not any other influenza viruses. Consequently, H1N1, H3N2, and both IBV lineages are in circulation in seasonal form.[27][43][42]
In 2011, IDV was discovered in pigs in Oklahoma, USA, and cattle were later identified as the primary reservoir of IDV.[29][35] In the same year,[81] avian H7N9 was detected in China and began to cause human infections in 2013, starting in Shanghai and Anhui and remaining mostly in China. HPAI H7N9 emerged sometime in 2016 and has occasionally infected humans incidentally. Other AIVs have less commonly infected humans since the 1990s, including H5N6, H6N1, H7N2-4, H7N7, and H10N7-8,[33] and HPAI H subtypes such as H5N-3, H5N5-6, and H5N8 have begun to spread throughout much of the world since the 2010s. Future flu pandemics, which may be caused by an influenza virus of avian origin,[43] are viewed as almost inevitable, and increased globalization has made it easier for novel viruses to spread,[42] so there are continual efforts to prepare for future pandemics[94] and improve the prevention and treatment of influenza.[27]
Etymology
The word influenza comes from the Italian word influenza, from medieval Latin influentia, originally meaning "visitation" or "influence" of the stars. This referred to the disease's cause, which at the time was ascribed by some to unfavorable astrological conditions. Its use in the disease sense is first attested in 1504, when it meant a "visitation" or "outbreak" of any disease affecting many people in a single place at once. During an outbreak of influenza in 1743 that started in Italy and spread throughut Europe, the word reached the English language and was anglicized in pronunciation.[100][101] Other names that have been used for influenza include epidemic catarrh, la grippe from French, sweating sickness, and, especially when referring to the 1918 pandemic strain, Spanish fever.[102]
Research
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Research on influenza includes studies on molecular virology, how the virus produces disease (pathogenesis), host immune responses, viral genomics, and how the virus spreads (epidemiology). These studies help in developing influenza countermeasures; for example, a better understanding of the body's immune system response helps vaccine development, and a detailed picture of how influenza invades cells aids the development of antiviral drugs. One important basic research program is the Influenza Genome Sequencing Project, which was initiated in 2004 to create a library of influenza sequences and help clarify which factors make one strain more lethal than another, which genes most affect immunogenicity, and how the virus evolves over time.[103]
The sequencing of the influenza genome and recombinant DNA technology may accelerate the generation of new vaccine strains by allowing scientists to substitute new antigens into a previously developed vaccine strain.[104] Growing viruses in cell culture also promises higher yields, less cost, better quality and surge capacity.[105] Research on a universal influenza A vaccine, targeted against the external domain of the transmembrane viral M2 protein (M2e), is being done at the University of Ghent by Walter Fiers, Xavier Saelens and their team[106][107][108] and has now successfully concluded Phase I clinical trials. There has been some research success towards a "universal flu vaccine" that produces antibodies against proteins on the viral coat which mutate less rapidly, and thus a single shot could potentially provide longer-lasting protection.[109][110][111]
A number of biologics, therapeutic vaccines and immunobiologics are also being investigated for treatment of infection caused by viruses. Therapeutic biologics are designed to activate the immune response to virus or antigens. Typically, biologics do not target metabolic pathways like anti-viral drugs, but stimulate immune cells such as lymphocytes, macrophages, and/or antigen-presenting cells, in an effort to drive an immune response towards a cytotoxic effect against the virus. Influenza models, such as murine influenza, are convenient models to test the effects of prophylactic and therapeutic biologics. For example, lymphocyte T-cell immunomodulator inhibits viral growth in the murine model of influenza.[112]
In animals
Birds
Aquatic birds such as ducks, geese, shorebirds, and gulls are the primary reservoir of IAVs.[33][34] In birds, AIVs may be either low pathogenic avian influenza (LPAI) viruses that produce little to no symptoms or highly pathogenic avian influenza (HPAI) viruses that cause severe illness. Symptoms of HPAI infection include lack of energy and appetite, decreased egg production, soft-shelled or misshapen eggs, swelling of the head, comb, wattles, and hocks, purple discoloration of wattles, combs, and legs, nasal discharge, coughing, sneezing, incoordination, and diarrhea. Birds infected with an HPAI virus may also die suddenly without any signs of infection.[80]
The distinction between LPAI and HPAI can generally be made based on how lethal an AIV is to chickens. At the genetic level, an AIV can be usually be identified as an HPAI virus if it has a multibasic cleavage site in the HA protein, which contains additional residues in the HA gene.[34][43] Most AIVs are LPAI. Notable HPAI viruses include HPAI H5N1 and HPAI H7N9. HPAI viruses have been a major disease burden in the 21st century, resulting in the death of large numbers of birds. In H7N9's case, some circulating strains were originally LPAI but became HPAI by acquiring the HA multibasic cleavage site. Avian H9N2 is also of concern because although it is LPAI, it is a common donor of genes to H5N1 and H7N9 during reassortment.[27]
Migratory birds can spread influenza across long distances. An example of this was when an H5N1 strain in 2005 infected birds at Qinghai Lake, China, which is a stopover and breeding site for many migratory birds, subsequently spreading the virus to more than 20 countries across Asia, Europe, and the Middle East.[33][43] AIVs can be transmitted from wild birds to domestic free-range ducks and in turn to poultry through contaminated water, aerosols, and fomites.[27] Ducks therefore act as key intermediates between wild and domestic birds.[43] Transmission to poultry typically occurs in backyard farming and live animal markets where multiple species interact with each other. From there, AIVs can spread to poultry farms in the absence of adequate biosecurity. Among poultry, HPAI transmission occurs through aerosols and contaminated feces,[27] cages, feed, and dead animals.[33] Back-transmission of HPAI viruses from poultry to wild birds has occurred and is implicated in mass die-offs and intercontinental spread.[34]
AIVs have occasionally infected humans through aerosols, fomites, and contaminted water.[27] Direction transmission from wild birds is rare.[43] Instead, most transmission involves domestic poultry, mainly chickens, ducks, and geese but also a variety of other birds such as guinea fowl, partridge, pheasants, and quails.[34] The primary risk factor for infection with AIVs is exposure to birds in farms and live poultry markets.[33] Typically, infection with an AIV has an incubation period of 3–5 days but can be up to 9 days. H5N1 and H7N9 cause severe lower respiratory tract illness, whereas other AIVs such as H9N2 cause a more mild upper respiratory tract illness, commonly with conjunctivitis.[27] Limited transmission of avian H2, H5-7, H9, and H10 subtypes from one person to another through respiratory droplets, aerosols, and fomites has occurred,[27][36] but sustained human-to-human transmission of AIVs has not occurred. Before 2013, H5N1 was the most common AIV to infect humans. Since then, H7N9 has been responsible for most human cases.[33]
Pigs
Influenza in pigs is a respiratory disease similar to influenza in humans and is found worldwide. Asymptomatic infections are common. Symptoms typically appear 1–3 days after infection and include fever, lethargy, anorexia, weight loss, labored breathing, coughing, sneezing, and nasal discharge. In sows, pregnancy may be aborted. Complications include secondary infections and potentially fatal bronchopneumonia. Pigs become contagious within a day of infection and typically spread the virus for 7–10 days, which can spread rapidly within a herd. Pigs usually recover from infection within 3–7 days after symptoms appear. Prevention and control measures include inactivated vaccines and culling infected herds. The influenza viruses usually responsible for swine flu are IAV subtypes H1N1, H1N2, and H3N2.[113]
Some IAVs can be transmitted via aerosols from pigs to humans and vice versa.[27] Furthermore, pigs, along with bats and quails,[35] are recognized as a mixing vessel of influenza viruses because that have both α-2,3 and α-2,6 sialic acid receptors in their respiratory tract. Because of that, both avian and mammalian influenza viruses can infect pigs. If co-infection occurs, then reassortment is possible.[34] A notable example of this was the reassortment of a swine, avian, and human influenza virus in 2009, resulting in a novel H1N1 strain that caused the 2009 flu pandemic.[34][79] Spillover events from humans to pigs, however, appear to be more common than from pigs to humans.[34]
Other animals
Influenza viruses have been found in many other animals, including cattle, horses, dogs, cats, and marine mammals. Nearly all IAVs are apparently descended from ancestral viruses in birds. The exception are bat influenza-like viruses, which have an uncertain origin. These bat viruses have HA and NA subtypes H17, H18, N10, and N11. H17N10 and H18N11 are unable to reassort with other IAVs, but they are still able to replicate in other mammals.[27] AIVs sometimes crossover into mammals. For example, in late 2016 to early 2017, an avian H7N2 strain was found to be infecting cats in New York.[27]
Equine IAVs include H7N7 and two lineages[27] of H3N8. H7N7, however, has not been detected in horses since the late 1970s,[38] so it may have become extinct in horses.[34] H3N8 in equines spreads via aerosols and causes respiratory illness.[27] Equine H3N8 perferentially binds to α-2,3 sialic acids, so horses are usually considered dead-end hosts, but transmission to dogs and camels has occurred, raising concerns that horses may be mixing vessels for reassortment. In canines, the only IAVs in circulation are equine-derived H3N8 and avian-derived H3N2. Canine H3N8 has not been observed to reassort with other subtypes. H3N2 has a much broader host range and can reassort with H1N1 and H5N1. An isolated case of H6N1 likely from a chicken was found infecting a dog, so other AIVs may emerge in canines.[34]
Other mammals to be infected by IAVs include H7N7 and H4N5 in seals, H1N3 in whales, and H10N4 and H3N2 in minks.[38] Various mutations have been identified that are associated with AIVs adapting to mammals. Since HA proteins vary in which sialic acids they bind to, mutations in the HA receptor binding site can allow AIVs to infect mammals. Other mutations include include mutations affecting which sialic acids NA proteins cleave and a mutation in the PB2 polymerase subunit that improves tolerance of lower temperatures in mammalian respiratory tracts and enhances RNP assembly by stabilizing NP and PB2 binding.[34]
IBV is mainly found in humans but has also been detected in pigs, dogs, horses, and seals.[35] Likewise, ICV primarily infects humans but has been observed in pigs, dogs, cattle, and dromedary camels.[29][35] IDV causes an influenza-like illness in pigs but its impact in its natural reservoir, cattle, is relatively unknown. It may cause respiratory disease resembling human influenza on its own, or it may be part of a bovine respiratory disease (BRD) complex with other pathogens during co-infection. BRD is a concern for the cattle industry, so IDV's possible involvement in BRD has led to the research on vaccines for cattle that can provide protection against IDV.[35][37] Two antigenic lineages are in circulation: D/swine/Oklahoma/1334/2011 (D/OK) and D/bovine/Oklahoma/660/2013 (D/660).[35]
Notes
- ^ The two most common estimates of annual influenza mortality are 250,000 to 500,000 deaths and 290,000 to 650,000 deaths.
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