Avian influenza virus infections in humans

The lower serum immunoglobulin G2 level in severe cases than in mild cases of pandemic H1N1 2009 influenza is associated with cytokine dysregulation

The majority of patients with pandemic influenza H1N1 2009 had mild illness, but some, including those with no risk factors for severe disease, may succumb to this infection. Besides viral factors such as the D222/225G substitution of the hemagglutinin, host factors such as IgG2 subclass deficiency recently was reported to be associated with severe disease in a cohort of Australian patients besides other known risk factors, including underlying chronic illness, extremes of age, and pregnancy. We conducted a case-control study of 38 Asian patients with respiratory failure due to severe pandemic influenza and compared the results to those for 36 mild cases. None had selective IgG2 deficiency, but the level of IgG2 subclass was significantly lower in the severe cases (3.55 g/liter versus 4.75 g/liter; P = 0.002), whereas the levels of IgG1, IgG3, and IgG4 were not significantly different from those of the mild cases. Previous studies suggested that some IgHG2 and FcγRIIa genotypes were associated with IgG2 deficiency. The allelic frequency of the IgHG2 genotypes in our severe cases was not correlated with their levels of IgG2, while that of FcγRIIa was not significantly different from that of the general Han Chinese population (P = 0.216). Only the overall cytokine/chemokine profile (P = 0.029) and serum globulin level (P = 0.005) were found to be independently associated with the IgG2 level by multivariate analysis. The lower IgG2 level in our severe group might be related to cytokine dysregulation rather than being a significant risk factor for severe pandemic influenza. The importance of this finding for therapeutic intervention will require further studies of larger cohorts of patients.

H5N1 virus activates signaling pathways in human endothelial cells resulting in a specific imbalanced inflammatory response

H5N1 influenza virus infections in humans cause a characteristic systemic inflammatory response syndrome; however, the molecular mechanisms are largely unknown. Endothelial cells (ECs) play a pivotal role in hyperdynamic septic diseases. To unravel specific signaling networks activated by H5N1 we used a genome-wide comparative systems biology approach analyzing gene expression in human ECs infected with three different human and avian influenza strains of high and low pathogenicity. Blocking of specific signaling pathways revealed that H5N1 induces an exceptionally NF-κB-dependent gene response in human endothelia. Additionally, the IFN-driven antiviral program in ECs is shown to be dependent on IFN regulatory factor 3 but significantly impaired upon H5N1 infection compared with low pathogenic influenza virus. As additional modulators of this H5N1-specific imbalanced gene response pattern, we identified HMGA1 as a novel transcription factor specifically responsible for the overwhelming proinflammatory but not antiviral response, whereas NFATC4 was found to regulate transcription of specifically H5N1-induced genes. We describe for the first time, to our knowledge, defined signaling patterns specifically activated by H5N1, which, in contrast to low pathogenic influenza viruses, are responsible for an imbalance of an overwhelming proinflammatory and impaired antiviral gene program.

Protective immunity against H5N1 influenza virus by a single dose vaccination with virus-like particles

We generated influenza virus-like particles (VLPs) containing the wild type (WT) H5 hemagglutinin (HA) from A/Viet Nam/1203/04 virus or a mutant H5 HA with a deletion of the multibasic cleavage motif. VLPs containing mutant H5 HA were found to be as immunogenic as VLPs containing WT HA. A single intramuscular vaccination with either type of H5 VLPs provided complete protection against lethal challenge. In contrast, the recombinant H5 HA vaccine was less immunogenic and vaccination even with a 5 fold higher dose did not induce protective immunity. VLP vaccines were superior to the recombinant HA in inducing T helper type 1 immune responses, hemagglutination inhibition titers, and antibody secreting cells, which significantly contribute to inducing protective immunity after a single dose vaccination. This study provides insights into the potential mechanisms of improved immunogenicity by H5 VLP vaccines as an approach to improve the protective efficacy against potential pandemic viruses.

Field evidence of the efficacy of vaccination to control low pathogenicity avian influenza in meat turkeys

This paper analyzes the efficacy of vaccination to control low pathogenicity avian influenza outbreaks using information collected during four epidemics occurring in Italy between 2000 and 2005. Different vaccination strategies and protocols for meat-turkey immunization are also considered.

Identification of influenza A nucleoprotein as an antiviral target

The spread of influenza virus strains resistant to the current generation of anti-viral drugs makes the identification of new druggable targets and lead compounds of prime importance. Kao et al. show that the influenza A nucleoprotein can be targeted by a small molecule that protects mice from lethal viral challenges.

Influenza A remains a significant public health challenge because of the emergence of antigenically shifted or highly virulent strains^1,2,3,4,5. Antiviral resistance to available drugs such as adamantanes or neuraminidase inhibitors has appeared rapidly^6,7,8,9, creating a need for new antiviral targets and new drugs for influenza virus infections. Using forward chemical genetics, we have identified influenza A nucleoprotein (NP) as a druggable target and found a small-molecule compound, nucleozin, that triggers the aggregation of NP and inhibits its nuclear accumulation. Nucleozin impeded influenza A virus replication in vitro with a nanomolar median effective concentration (EC₅₀) and protected mice challenged with lethal doses of avian influenza A H5N1. Our results demonstrate that viral NP is a valid target for the development of small-molecule therapies.

Delayed clearance of viral load and marked cytokine activation in severe cases of pandemic H1N1 2009 influenza virus infection

BACKGROUND

Infections caused by the pandemic H1N1 2009 influenza virus range from mild upper respiratory tract syndromes to fatal diseases. However, studies comparing virological and immunological profile of different clinical severity are lacking.

METHODS

We conducted a retrospective cohort study of 74 patients with pandemic H1N1 infection, including 23 patients who either developed acute respiratory distress syndrome (ARDS) or died (ARDS-death group), 14 patients with desaturation requiring oxygen supplementation and who survived without ARDS (survived-without-ARDS group), and 37 patients with mild disease without desaturation (mild-disease group). We compared their pattern of clinical disease, viral load, and immunological profile.

RESULTS

Patients with severe disease were older, more likely to be obese or having underlying diseases, and had lower respiratory tract symptoms, especially dyspnea at presentation. The ARDS-death group had a slower decline in nasopharyngeal viral loads, had higher plasma levels of proinflammatory cytokines and chemokines, and were more likely to have bacterial coinfections (30.4%), myocarditis (21.7%), or viremia (13.0%) than patients in the survived-without-ARDS or the mild-disease groups. Reactive hemophagocytosis, thrombotic phenomena, lymphoid atrophy, diffuse alveolar damage, and multiorgan dysfunction similar to fatal avian influenza A H5N1 infection were found at postmortem examinations.

CONCLUSIONS

The slower control of viral load and immunodysregulation in severe cases mandate the search for more effective antiviral and immunomodulatory regimens to stop the excessive cytokine activation resulting in ARDS and death.

Neuraminidase and hemagglutinin matching patterns of a highly pathogenic avian and two pandemic H1N1 influenza A viruses

Background

Influenza A virus displays strong reassortment characteristics, which enable it to achieve adaptation in human infection. Surveying the reassortment and virulence of novel viruses is important in the prevention and control of an influenza pandemic. Meanwhile, studying the mechanism of reassortment may accelerate the development of anti-influenza strategies.

Methodology/Principal Findings

The hemagglutinin (HA) and neuraminidase (NA) matching patterns of two pandemic H1N1 viruses (the 1918 and current 2009 strains) and a highly pathogenic avian influenza A virus (H5N1) were studied using a pseudotyped particle (pp) system. Our data showed that four of the six chimeric HA/NA combinations could produce infectious pps, and that some of the chimeric pps had greater infectivity than did their ancestors, raising the possibility of reassortment among these viruses. The NA of H5N1 (A/Anhui/1/2005) could hardly reassort with the HAs of the two H1N1 viruses. Many biological characteristics of HA and NA, including infectivity, hemagglutinating ability, and NA activity, are dependent on their matching pattern.

Conclusions/Significance

Our data suggest the existence of an interaction between HA and NA, and the HA NA matching pattern is critical for valid viral reassortment.

Bacterial pneumonias during an influenza pandemic: how will we allocate antibiotics?

We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committee's guiding principles for allocating antibiotics during a pandemic.

The natural viral load profile of patients with pandemic 2009 influenza A(H1N1) and the effect of oseltamivir treatment

BACKGROUND

The natural history of viral shedding from the upper respiratory tract of the new pandemic 2009 influenza A(H1N1) and the effect of oseltamivir treatment were uncertain.

METHODS

A retrospective cohort study involving 145 consecutive patients with specimens positive by reverse transcriptase-polymerase chain reaction for the matrix and new H1 genes was conducted.

RESULTS

The nontreated and oseltamivir-treated patients were comparable in their viral load at presentation, demography, and the presenting symptoms. No correlation was observed between viral load with age and number of symptoms. Viral load of nasopharyngeal aspirate (NPA) was significantly lower in treated than in nontreated patients at day 5 after symptom onset. When oseltamivir was initiated </= 2 days after symptom onset, a greater rate of viral load reduction in NPA of treated patients than that of nontreated patients was observed (-0.638 [95% CI, -0.809 to -0.466] vs -0.409 [95% CI, -0.663 to -0.185] log(10) copies/mL/d post-symptom onset), and the viral load was undetectable at day 6 after oseltamivir initiation, which was 1 day earlier than that of those whose treatment was initiated > 2 days of symptom onset. The viral load was inversely correlated with concomitant absolute lymphocyte count in nontreated patients (Pearson correlation coefficient [r] = -0.687, P = .001) and treated patients (Pearson r = -0.365, P < .001). Resolution of fever was 1.4 days later in nontreated than treated patients (P = .012)

CONCLUSIONS

The natural viral load profile was described. Oral oseltamivir suppresses viral load more effectively when given early in mild cases of pandemic 2009 influenza A(H1N1) infections.

Vaccination of poultry workers: delivery and uptake of seasonal influenza immunization

Avian influenza is a highly infectious disease in poultry and although the risk of human infection is low, concerns exist that it could evolve into a new human strain of pandemic potential if reassortment with a human influenza virus occurs. In January 2007, the UK government introduced a programme to vaccinate poultry workers to reduce the potential of such an event. This study evaluates the delivery, uptake and costs of the programme in three counties of England. A questionnaire survey was completed by consultants in public health in all the Primary Care Trusts in Norfolk, Suffolk and Cambridgeshire in May 2007. The delivery of the programme varied between Primary Care Trusts, including being delivered in some cases by clinics in primary care, by general practitioners and occupational health services in others. The uptake of vaccination was low ranging from 7% to 29% at a cost of £29 to £132 per person vaccinated. Vaccination of poultry workers as a public health measure to prevent an influenza pandemic is likely to be ineffective with the level of coverage found in this evaluation in our region.

Tissue and host tropism of influenza viruses: importance of quantitative analysis

It is generally accepted that human influenza viruses preferentially bind to cell-surface glycoproteins/glycolipids containing sialic acids in alpha2,6-linkage; while avian and equine influenza viruses preferentially bind to those containing sialic acids in alpha2,3-linkage. Even though this generalized view is accurate for H3 subtype isolates, it may not be accurate and absolute for all subtypes of influenza A viruses and, therefore, needs to be reevaluated carefully and realistically. Some of the studies published in major scientific journals on the subject of tissue tropism of influenza viruses are inconsistent and caused confusion in the scientific community. One of the reasons for the inconsistency is that most studies were quantitative descriptions of sialic acid receptor distributions based on lectin or influenza virus immunohistochemistry results with limited numbers of stained cells. In addition, recent studies indicate that alpha2,3- and alpha2,6-linked sialic acids are not the sole receptors determining tissue and host tropism of influenza viruses. In fact, determinants for tissue and host tropism of human, avian and animal influenza viruses are more complex than what has been generally accepted. Other factors, such as glycan topology, concentration of invading viruses, local density of receptors, lipid raft microdomains, coreceptors or sialic acid-independent receptors, may also be important. To more efficiently control the global spread of pandemic influenza such as the current circulating influenza A H1N1, it is crucial to clarify the determinants for tissue and host tropism of influenza viruses through quantitative analysis of experimental results. In this review, I will comment on some conflicting issues related to tissue and host tropism of influenza viruses, discuss the importance of quantitative analysis of lectin and influenza virus immunohistochemistry results and point out directions for future studies in this area, which should lead to a better understanding of tissue and host tropism of influenza viruses.

Lung pathology in fatal novel human influenza A (H1N1) infection

RATIONALE

There are no reports of the systemic human pathology of the novel swine H1N1 influenza (S-OIV) infection.

OBJECTIVES

The autopsy findings of 21 Brazilian patients with confirmed S-OIV infection are presented. These patients died in the winter of the southern hemisphere 2009 pandemic, with acute respiratory failure.

METHODS

Lung tissue was submitted to virologic and bacteriologic analysis with real-time reverse transcriptase polymerase chain reaction and electron microscopy. Expression of toll-like receptor (TLR)-3, IFN-gamma, tumor necrosis factor-alpha, CD8(+) T cells and granzyme B(+) cells in the lungs was investigated by immunohistochemistry.

MEASUREMENTS AND MAIN RESULTS

Patients were aged from 1 to 68 years (72% between 30 and 59 yr) and 12 were male. Sixteen patients had preexisting medical conditions. Diffuse alveolar damage was present in 20 individuals. In six patients, diffuse alveolar damage was associated with necrotizing bronchiolitis and in five with extensive hemorrhage. There was also a cytopathic effect in the bronchial and alveolar epithelial cells, as well as necrosis, epithelial hyperplasia, and squamous metaplasia of the large airways. There was marked expression of TLR-3 and IFN-gamma and a large number of CD8(+) T cells and granzyme B(+) cells within the lung tissue. Changes in other organs were mainly secondary to multiple organ failure.

CONCLUSIONS

Autopsies have shown that the main pathological changes associated with S-OIV infection are localized to the lungs, where three distinct histological patterns can be identified. We also show evidence of ongoing pulmonary aberrant immune response. Our results reinforce the usefulness of autopsy in increasing the understanding of the novel human influenza A (H1N1) infection.

Evaluation of interventions and vaccination strategies for low pathogenicity avian influenza: spatial and space-time analyses and quantification of the spread of infection

In recent years the control of low pathogenicity avian influenza (LPAI) viruses of the H5 and H7 subtypes has increasingly become a concern. We evaluated the measures (stamping out, controlled marketing, emergency and preventive vaccination, farm density reduction and restocking in homogenous areas) implemented to control the LPAI epidemics that occurred in Italy between 2000 and 2005, using a combination of spatial and space-time analyses and estimates of the basic reproduction ratio (R0). Clustering of infected farms decreased over the years, indicating the effectiveness of the control strategies implemented. Controlled marketing [relative risk (RR) 0.46, 95% confidence interval (CI) 0.27-0.80], emergency (RR 0.47, 95% CI 0.39-0.57) and preventive vaccination (RR 0.19, 95% CI 0.09-0.41) were the most effective measures, yet R0<1 was only for preventive vaccination. Our results are useful for identifying the most effective measures for reducing the risk of the spread of LPAI and optimizing the allocation of resources.

Pneumonia and respiratory failure from swine-origin influenza A (H1N1) in Mexico

BACKGROUND

In late March 2009, an outbreak of a respiratory illness later proved to be caused by novel swine-origin influenza A (H1N1) virus (S-OIV) was identified in Mexico. We describe the clinical and epidemiologic characteristics of persons hospitalized for pneumonia at the national tertiary hospital for respiratory illnesses in Mexico City who had laboratory-confirmed S-OIV infection, also known as swine flu.

METHODS

We used retrospective medical chart reviews to collect data on the hospitalized patients. S-OIV infection was confirmed in specimens with the use of a real-time reverse-transcriptase-polymerase-chain-reaction assay.

RESULTS

From March 24 through April 24, 2009, a total of 18 cases of pneumonia and confirmed S-OIV infection were identified among 98 patients hospitalized for acute respiratory illness at the National Institute of Respiratory Diseases in Mexico City. More than half of the 18 case patients were between 13 and 47 years of age, and only 8 had preexisting medical conditions. For 16 of the 18 patients, this was the first hospitalization for their illness; the other 2 patients were referred from other hospitals. All patients had fever, cough, dyspnea or respiratory distress, increased serum lactate dehydrogenase levels, and bilateral patchy pneumonia. Other common findings were an increased creatine kinase level (in 62% of patients) and lymphopenia (in 61%). Twelve patients required mechanical ventilation, and seven died. Within 7 days after contact with the initial case patients, a mild or moderate influenza-like illness developed in 22 health care workers; they were treated with oseltamivir, and none were hospitalized.

CONCLUSIONS

S-OIV infection can cause severe illness, the acute respiratory distress syndrome, and death in previously healthy persons who are young to middle-aged. None of the secondary infections among health care workers were severe.

A cell-based H7N1 split influenza virion vaccine confers protection in mouse and ferret challenge models

BACKGROUND

In recent years, several avian influenza subtypes (H5, H7 and H9) have transmitted directly from birds to man, posing a pandemic threat.

OBJECTIVES

We have investigated the immunogenicity and protective efficacy of a cell based candidate pandemic influenza H7 vaccine in pre-clinical animal models.

METHODS

Mice and ferrets were immunised with two doses of the split virus vaccine (12-24 microg haemagglutinin) with or without aluminium hydroxide adjuvant and challenged 3 weeks after second dose with the highly pathogenic A/chicken/Italy/13474/99 (H7N1) virus. The H7N1-specific serum antibody response was also measured. After challenge, viral shedding, weight loss, disease signs and death (only mice) were recorded.

RESULTS

Low-to-modest serum antibody titres were detected after vaccination. Nevertheless, the vaccine induced significant protection from disease after challenge with the wild-type virus. In the murine lethal challenge model, vaccination effectively prevented death and, furthermore, formulation with adjuvant reduced excessive weight loss and viral shedding. In ferrets, vaccination reduced viral shedding and protected against systemic spread of the virus.

CONCLUSIONS

We have extended to the H7 subtype the finding that protective efficacy may not be directly correlated with the pre-challenge levels of serum antibodies, a finding which could be of great importance in assessing the potential effectiveness of pandemic influenza vaccines.

Cross-neutralisation of antibodies elicited by an inactivated split-virion influenza A/Vietnam/1194/2004 (H5N1) vaccine in healthy adults against H5N1 clade 2 strains

Background  Highly pathogenic avian influenza A H5N1 viruses are widespread in different parts of the world and have evolved into clade 1 and 2 lineages. Their continuing circulation represents serious pandemic threat, spurring human vaccine development efforts. Initial clinical trials tested vaccines prepared from clade 1 strains circulating in 2004.

Methods  Post‐vaccination sera from a phase I trial of an inactivated split‐virion vaccine based on A/Vietnam/1194/2004/NIBRG14 (H5N1) were analysed in vitro for cross‐reactivity against highly pathogenic, wild‐type clade 2 H5N1 strains isolated from human cases, and their corresponding reverse genetics derived vaccine candidate strains.

Results  Neutralisation of clade 1 and 2 wild‐type and reverse‐genetics viruses was seen, with highest titres observed for viruses most closely related to the vaccine strain. There was no consistent relationship between vaccine dose given, or presence of aluminium adjuvant and cross‐neutralising antibody titre, possibly because of small sample size. Use of wild‐type highly pathogenic strains compared with antigenically equivalent reverse‐genetics viruses suggests presence of a higher level of cross‐neutralising antibody.

Conclusion  Vaccination with a clade 1 H5N1 virus elicited antibodies capable of neutralising diverse clade 2 H5N1 strains. This data underlines that while a close match between vaccine virus and circulating virus is important to achieve maximum protection, population priming with a ‘pre‐pandemic’ vaccine may be beneficial for the protection of a naïve population. The data suggests that use of reverse‐genetic viruses in neutralisation assays may underestimate the extent of cross‐protective antibody present following H5N1 vaccination.

H5N1 strain-specific hemagglutinin CD4+ T cell epitopes restricted by HLA DR4

CD4+ T cells play a pivotal role in the viral immunity, and as such identification of unique strain-specific HLA class II restricted epitopes is essential for monitoring cellular strain-specific viral immunity. Using Tetramer-Guided Epitope Mapping technique, we identified HLA-DR0401 restricted HA epitopes that are strain-specific to H5N1 virion. Two immunodominant epitopes H5HA(441-460) and H5HA(57-76) were identified from in vitro stimulated human PBMC. Both epitopes elicit strong cellular immune responses when HLA-DR0401 transgenic mice are immunized with H5N1 subvirion indicating in vivo naturally processed immunodominant epitopes. The H5HA(57-76) epitope is unique for the H5N1 strain but conserved among all H5N1 clades recommended for vaccine development by World Health Organization. The unique H5HA(57-76) response was uncommon in unexposed individuals and only observed in the naïve T cell subset. Thus, H5N1 strain-specific H5HA(57-76) immunogenic epitope represents a unique marker for monitoring the efficacy of vaccination or as a candidate vaccine peptide.

Monoclonal antibody recognizing SLLTEVET epitope of M2 protein potently inhibited the replication of influenza A viruses in MDCK cells

The ectodomain of influenza A virus M2 protein (M2e) is composed of 24 amino acids and induces antibodies with inhibitory effect against a broad spectrum of influenza A subtypes in vitro and in vivo. Although relatively conserved, 21 M2e variants emerged in recent influenza A strains, most of the mutations appeared in the middle part of M2e domain. In this study, we characterized the in vitro inhibition efficacy of a monoclonal antibody (mAb) M2e8-7 recognizing the N terminus highly conserved epitope SLLTEVET (aa 2-9) which is common for both M1 and M2 proteins. Peptide binding assay showed that mAb M2e8-7 reacted strongly with M2e and 19 M2e variant peptides. The mAb M2e8-7 potently inhibited the replication of influenza A virus H1 and H3 subtypes in MDCK cells. Two important amino acids in M2e epitope, Threonine at position five and the Glutamic acid at position six, were identified to lead antibody-escaping variants. These results brought new insight in developing vaccine and therapeutic agents against influenza A virus infections.

Conserved amino acid markers from past influenza pandemic strains

Background

Finding the amino acid mutations that affect the severity of influenza infections remains an open and challenging problem. Of special interest is better understanding how current circulating influenza strains could evolve into a new pandemic strain. Influenza proteomes from distinct viral phenotype classes were searched for class specific amino acid mutations conserved in past pandemics, using reverse engineered linear classifiers.

Results

Thirty-four amino acid markers associated with host specificity and high mortality rate were found. Some markers had little impact on distinguishing the functional classes by themselves, however in combination with other mutations they improved class prediction. Pairwise combinations of influenza genomes were checked for reassortment and mutation events needed to acquire the pandemic conserved markers. Evolutionary pathways involving H1N1 human and swine strains mixed with avian strains show the potential to acquire the pandemic markers with a double reassortment and one or two amino acid mutations.

Conclusion

The small mutation combinations found at multiple protein positions associated with viral phenotype indicate that surveillance tools could monitor genetic variation beyond single point mutations to track influenza strains. Finding that certain strain combinations have the potential to acquire pandemic conserved markers through a limited number of reassortment and mutation events illustrates the potential for reassortment and mutation events to lead to new circulating influenza strains.

A proposed taxonomy for characterization and assessment of avian influenza outbreaks

PURPOSE

The speed and high potential impact of avian influenza's (AI) on local bird populations, poultry economies and human health make timely and coordinated characterization, assessment and response to possible threats essential. To collaborate effectively, stakeholders (public health, medical, veterinary, and agricultural professionals) must be able to communicate and record findings, assessments, and actions in a standard fashion. We seek to discern a taxonomy of concepts and relationships that are important to the stakeholder community when sharing information about the characterization and assessment of an AI outbreak, according to a consistent and common perspective, interpretation, and level of detail.

METHODS

To derive concepts relevant to AI characterization and assessment, we reviewed selected journal articles, reporting and laboratory forms, and public health websites associated with AI case reporting. We mapped concepts to existing medical terminologies within the Unified Medical Language System when possible, using the National Library of Medicine's MetaMap program.

RESULTS

From 54 distinct information sources, we extracted 1113 concepts, of which 533 mapped to 15 medical terminologies; 580 did not map to specific terminologies. Using a combination of semantic type-relationship matching and expert consensus, we constructed the proposed taxonomy, with linkages to existing terminologies where pragmatic.

CONCLUSION

The proposed taxonomy describes core knowledge, data and communication needs for the characterization and assessment of AI outbreaks in the context of existing medical terminologies across different domains. We also describe areas for further work.

Early and sustained innate immune response defines pathology and death in nonhuman primates infected by highly pathogenic influenza virus

The mechanisms responsible for the virulence of the highly pathogenic avian influenza (HPAI) and of the 1918 pandemic influenza virus in humans remain poorly understood. To identify crucial components of the early host response during these infections by using both conventional and functional genomics tools, we studied 34 cynomolgus macaques (Macaca fascicularis) to compare a 2004 human H5N1 Vietnam isolate with 2 reassortant viruses possessing the 1918 hemagglutinin (HA) and neuraminidase (NA) surface proteins, known conveyors of virulence. One of the reassortants also contained the 1918 nonstructural (NS1) protein, an inhibitor of the host interferon response. Among these viruses, HPAI H5N1 was the most virulent. Within 24 h, the H5N1 virus produced severe bronchiolar and alveolar lesions. Notably, the H5N1 virus targeted type II pneumocytes throughout the 7-day infection, and induced the most dramatic and sustained expression of type I interferons and inflammatory and innate immune genes, as measured by genomic and protein assays. The H5N1 infection also resulted in prolonged margination of circulating T lymphocytes and notable apoptosis of activated dendritic cells in the lungs and draining lymph nodes early during infection. While both 1918 reassortant viruses also were highly pathogenic, the H5N1 virus was exceptional for the extent of tissue damage, cytokinemia, and interference with immune regulatory mechanisms, which may help explain the extreme virulence of HPAI viruses in humans.

Long-term psychiatric morbidities among SARS survivors

OBJECTIVE

Severe acute respiratory syndrome (SARS) was the first massive infectious disease outbreak of the 21st century. However, it is unlikely that this outbreak will be the last. This study aimed to evaluate the long-term psychiatric morbidities in survivors of SARS.

METHOD

This is a cohort study designed to investigate psychiatric complications among SARS survivors treated in the United Christian Hospital 30 months after the SARS outbreak. Psychiatric morbidities were assessed by the Structured Clinical Interview for DSM-IV, the Impact of Events Scale-Revised and the Hospital Anxiety and Depression Scale. Functional outcomes were assessed by the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Ninety subjects were recruited, yielding a response rate of 96.8%. Post-SARS cumulative incidence of DSM-IV psychiatric disorders was 58.9%. Current prevalence for any psychiatric disorder at 30 months post-SARS was 33.3%. One-fourth of the patients had post-traumatic stress disorder (PTSD), and 15.6% had depressive disorders.

CONCLUSION

The outbreak of SARS can be regarded as a mental health catastrophe. PTSD was the most prevalent long-term psychiatric condition, followed by depressive disorders. Our results highlight the need to enhance preparedness and competence of health care professionals in detecting and managing the psychological sequelae of future comparable infectious disease outbreaks.

Evaluation of student abilities to respond to a "real-world" question about an emerging infectious disease

Veterinarians play an important role in educating the public about emerging animal and zoonotic diseases. This article investigates the ability of third-year veterinary students (N=31), from a veterinary school in the USA, to respond to an actual client's question about an emerging disease. In an open-book, take-home examination, students were asked to respond to a nurse's concern that she could bring home influenza from work and infect her macaw. While 75% of the students answered the question correctly, only 51% demonstrated that they understood that this question came from the ongoing publicity about the highly pathogenic H5N1 avian influenza outbreak in Asia, Africa, and Europe. Additional information that would have decreased the client's concern and provided the client with a better understanding of this disease outbreak was lacking in many of the answers. The results of this study suggest that greater emphasis should be applied to exercises requiring veterinary students to research, carefully study, and formulate answers to applied topics that are novel to them.

design of multiplexed detection assays for identification of avian influenza a virus subtypes pathogenic to humans by SmartCycler real-time reverse transcription-PCR

Influenza A virus (IAV) epidemics are the result of human-to-human or poultry-to-human transmission. Tracking seasonal outbreaks of IAV and other avian influenza virus (AIV) subtypes that can infect humans, aquatic and migratory birds, poultry, and pigs is essential for epidemiological surveillance and outbreak alerts. In this study, we performed four real-time reverse transcription-PCR (rRT-PCR) assays for identification of the IAV M and hemagglutinin (HA) genes from six known AIVs infecting pigs, birds, and humans. IAV M1 gene-positive samples tested by single-step rRT-PCR and a fluorogenic Sybr green I detection system were further processed for H5 subtype identification by using two-primer-set multiplex and Sybr green I rRT-PCR assays. H5 subtype-negative samples were then tested with either a TaqMan assay for subtypes H1 and H3 or a TaqMan assay for subtypes H2, H7, and H9 and a beacon multiplex rRT-PCR identification assay. The four-tube strategy was able to detect 10 RNA copies of the HA genes of subtypes H1, H2, H3, H5, and H7 and 100 RNA copies of the HA gene of subtype H9. At least six H5 clades of H5N1 viruses isolated in Southeast Asia and China were detected by that test. Using rRT-PCR assays for the M1 and HA genes in 202 nasopharyngeal swab specimens from children with acute respiratory infections, we identified a total of 39 samples positive for the IAV M1 gene and subtypes H1 and H3. When performed with a portable SmartCycler instrument, the assays offer an efficient, flexible, and reliable platform for investigations of IAV and AIV in remote hospitals and in the field.

Stockpiling prepandemic influenza vaccines: a new cornerstone of pandemic preparedness plans

The history of pandemic influenza, along with the evolving epizootic of the highly pathogenic avian influenza A (H5N1) virus and the severity of associated human infections, serve as a warning to the world of the threat of another influenza pandemic. Conservative estimates suggest that up to 350 million people could die and many more would be affected, causing disruption to health-care systems, society, and the world's economy. WHO has encouraged countries to prepare in advance by developing influenza pandemic preparedness plans that involve public-health and pharmaceutical interventions. Vaccination is a cornerstone of these plans; however, a pandemic vaccine cannot be manufactured in advance because the next pandemic virus cannot be predicted. The concepts of vaccine stockpiling and prepandemic vaccination have thus become attractive. Human H5N1 vaccines are currently available and can induce heterotypic immunity. WHO and governments should give urgent consideration to the use of these vaccines for the priming of individuals or communities who would be at greatest risk of infection if an H5N1 influenza pandemic were to emerge.

Antiviral therapy for respiratory tract infections

Viruses are important pathogens causing respiratory tract infections both in the community and health-care facility settings. They are extremely common causes of morbidity in the competent hosts and some are associated with significant mortality in the compromised individuals. With wider application of molecular techniques, novel viruses are being described and old viruses are found to have new significance in different epidemiological and clinical settings. Some of these emerging pathogens may have the potential to cause pandemics or global spread of a severe disease, as exemplified by severe acute respiratory syndrome and avian influenza. Antiviral therapy of viral respiratory infections is often unnecessary in the competent hosts because most of them are selflimiting and effective agents are not always available. In the immunocompromised individuals or for infections caused by highly pathogenic viruses, such as avian influenza viruses (AIV), antiviral treatment is highly desirable, despite the fact that many of the agents may not have undergone stringent clinical trials. In immunocompetent hosts, antiviral therapy can be stopped early because adaptive immune response can usually be mounted within 5-14 days. However, the duration of antiviral therapy in immunosuppressed hosts depends on clinical and radiological resolution, the degree and duration of immunosuppression, and therefore maintenance therapy is sometimes needed after the initial response. Immunotherapy and immunoprophylaxis appear to be promising directions for future research. Appropriate and targeted immunomodulation may play an important adjunctive role in some of these infections by limiting the extent of end-organ damage and multi-organ failure in some fulminant infections.

H5N1 avian influenza virus induces apoptotic cell death in mammalian airway epithelial cells

In recent years, the highly pathogenic avian influenza virus H5N1 has raised serious worldwide concern about an influenza pandemic; however, the biology of H5N1 pathogenesis is largely unknown. To elucidate the mechanism of H5N1 pathogenesis, we prepared primary airway epithelial cells from alveolar tissues from 1-year-old pigs and measured the growth kinetics of three avian H5 influenza viruses (A/Crow/Kyoto/53/2004 [H5N1], A/Duck/Hong Kong/342/78 [H5N2], and A/Duck/Hong Kong/820/80 [H5N3]), the resultant cytopathicity, and possible associated mechanisms. H5N1, but not the other H5 viruses, strongly induced cell death in porcine alveolar epithelial cells (pAEpC), although all three viruses induced similar degrees of cytopathicity in chicken embryonic fibroblasts. Intracellular viral growth and the production of progeny viruses were comparable in pAEpC infected with each H5 virus. In contrast, terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling-positive cells were detected only in H5N1-infected pAEpC, and the activities of caspases 3, 8, and 9 were significantly elevated in pAEpC infected with H5N1, but not with H5N2 and H5N3. These results suggest that only H5N1 induces apoptosis in pAEpC. H5N1 cytopathicity was inhibited by adding the caspase inhibitor z-VAD-FMK; however, there were no significant differences in viral growth or release of progeny viruses. Further investigations using reverse genetics demonstrated that H5N1 hemagglutinin protein plays a critical role in inducing caspase-dependent apoptosis in infected pAEpC. H5N1-specific cytopathicity was also observed in human primary airway epithelial cells. Taken together, these data suggest that avian H5N1 influenza virus leads to substantial cell death in mammalian airway epithelial cells due to the induction of apoptosis.

Broad-spectrum drugs against viral agents

Development of antivirals has focused primarily on vaccines and on treatments for specific viral agents. Although effective, these approaches may be limited in situations where the etiologic agent is unknown or when the target virus has undergone mutation, recombination or reassortment. Augmentation of the innate immune response may be an effective alternative for disease amelioration. Nonspecific, broad-spectrum immune responses can be induced by double-stranded (ds)RNAs such as poly (ICLC), or oligonucleotides (ODNs) containing unmethylated deocycytidyl-deoxyguanosinyl (CpG) motifs. These may offer protection against various bacterial and viral pathogens regardless of their genetic makeup, zoonotic origin or drug resistance.

Testing human sera for antibodies against avian influenza viruses: horse RBC hemagglutination inhibition vs. microneutralization assays

BACKGROUND

The hemagglutination inhibition (HI) assay is a frequently used method to screen human sera for antibodies against influenza A viruses. Because HI has relatively poor sensitivity in detecting antibodies against avian influenza A strains, a more complicated microneutralization (MN) assay is often preferred. Recent research suggests that the sensitivity of the HI assay can be improved by switching from the traditionally used turkey, guinea pig, human, or chicken RBCs to horse RBCs.

OBJECTIVE

To evaluate the performance of the horse RBC HI when screening for human antibodies against avian influenza types H3, H4, H5, H6, H7, H9, H11, and H12.

STUDY DESIGN

We evaluated the reproducibility of horse RBC HI and its agreement with MN results using sera from people exposed or not exposed to wild and domestic birds.

RESULTS

The horse RBC HI assay had high reliability (90%-100%) and good agreement with MN assay results (52%-100%).

CONCLUSION

The horse RBC HI assay is reliable, less expensive, less complex, and faster than the MN assay. While MN will likely remain the gold standard serologic assay for avian viruses, the horse RBC HI assay may be very useful as a screening assay in large-scale epidemiologic studies.

Development of stable influenza vaccine powder formulations: challenges and possibilities

Influenza vaccination represents the cornerstone of influenza prevention. However, today all influenza vaccines are formulated as liquids that are unstable at ambient temperatures and have to be stored and distributed under refrigeration. In order to stabilize influenza vaccines, they can be brought into the dry state using suitable excipients, stabilizers and drying processes. The resulting stable influenza vaccine powder is independent of cold-chain facilities. This can be attractive for the integration of the vaccine logistics with general drug distribution in Western as well as developing countries. In addition, a stockpile of stable vaccine formulations of potential vaccines against pandemic viruses can provide an immediate availability and simple distribution of vaccine in a pandemic outbreak. Finally, in the development of new needle-free dosage forms, dry and stable influenza vaccine powder formulations can facilitate new or improved targeting strategies for the vaccine compound. This review represents the current status of dry stable inactivated influenza vaccine development. Attention is given to the different influenza vaccine types (i.e. whole inactivated virus, split, subunit or virosomal vaccine), the rationale and need for stabilized influenza vaccines, drying methods by which influenza vaccines can be stabilized (i.e. lyophilization, spray drying, spray-freeze drying, vacuum drying or supercritical fluid drying), the current status of dry influenza vaccine development and the challenges for ultimate market introduction of a stable and effective dry-powder influenza vaccine.

A method to provide improved dose-response estimates for airborne pathogens in animals: an example using porcine reproductive and respiratory syndrome virus

This paper describes a method to provide improved probability estimates that exposure to a specific dose of an airborne infectious pathogen will result in animal infection. Individual animals were exposed to a specific dose of airborne pathogen. Following exposure, animals were individually housed and monitored for evidence of infection. The detection of specific antibodies and/or the pathogen in diagnostic specimens was evidence that the exposure dose resulted in infection. If replicated over a range of doses, the results can be used to derive a dose-response curve for a variety of animal species and infectious pathogens. This information is useful in estimating the likelihood of infection associated with exposure to airborne infectious microorganisms. Applications include predicting the risk of transmission associated with exposure to airborne pathogens, modeling the transmission of airborne pathogens, and determining requirements for effective exposure doses for vaccines delivered in aerosols.

Bench-to-bedside review: rare and common viral infections in the intensive care unit--linking pathophysiology to clinical presentation

Viral infections are common causes of respiratory tract disease in the outpatient setting but much less common in the intensive care unit. However, a finite number of viral agents cause respiratory tract disease in the intensive care unit. Some viruses, such as influenza, respiratory syncytial virus (RSV), cytomegalovirus (CMV), and varicella-zoster virus (VZV), are relatively common. Others, such as adenovirus, severe acute respiratory syndrome (SARS)-coronavirus, Hantavirus, and the viral hemorrhagic fevers (VHFs), are rare but have an immense public health impact. Recognizing these viral etiologies becomes paramount in treatment, infection control, and public health measures. Therefore, a basic understanding of the pathogenesis of viral entry, replication, and host response is important for clinical diagnosis and initiating therapeutic options. This review discusses the basic pathophysiology leading to clinical presentations in a few common and rare, but important, viruses found in the intensive care unit: influenza, RSV, SARS, VZV, adenovirus, CMV, VHF, and Hantavirus.

Intensive care management of life-threatening avian influenza A (H5N1)

A large proportion of patients with avian influenza A (H5N1) develop life-threatening manifestations, often including ARDS, acute renal failure and multiple organ failure that requires aggressive intensive care management. The pace of development of respiratory failure is often rapid and can occur in previously healthy hosts, mandating close observation and timely intervention of infected individuals. Use of standard, contact, droplet and airborne isolation precautions is recommended to protect healthcare workers. Key components of ARDS management encompass appropriate mechanical ventilation including limiting tidal volume to </=6 mL/kg of predicted body weight, maintaining transpulmonary pressures </=30 cm H(2)O, and utilizing positive end-expiratory pressure to limit alveolar deflation and to improve oxygenation. Additional strategies include conservative fluid management and using nutrition supplemented with antioxidants. Use of corticosteroids is controversial for both early and late ARDS and although often used for avian influenza, beneficial effects on outcomes have not been demonstrated for corticosteroids. Prone positioning can improve oxygenation temporarily and might be useful as rescue therapy for severe hypoxemia. Administration of inhaled nitric oxide and high frequency oscillatory ventilation can improve oxygenation but have not been demonstrated to improve survival in ARDS-their role in avian influenza is uncertain and availability limited. Management of multiple organ failure may include vasopressor support for septic shock and renal replacement therapy for acute renal failure.

Die Bedeutung der aviären Influenza für das Gesundheitssystem

Die aviäre Influenza ist eine Viruskrankheit, die insbesondere Vögel befällt. Die auslösenden Erreger der Erkrankung sind Influenza-Viren. Die Erkrankung ist weltweit bekannt und wurde erstmals 1878 in Italien beschrieben. Influenza-Viren gehören zur Gruppe der Orthomyxoviridae. Das Influenza-A-Virus H5N1 gilt seit seiner sprunghaften Ausbreitung unter Geflügel im Jahre 2003 als möglicher Auslöser einer neuen Pandemie.

H5N1 ist humanpathogen, es besteht keine Immunität beim Menschen und es ist hochpathogen mit einer Mortalitätsrate von über 60%. Die wesentliche, bisher fehlende Eigenschaft des Virus um eine Pandemie auszulösen, ist die mangelnde effektive Übertragung von Mensch zu Mensch. Der vorliegende Übersichtsartikel befasst sich mit der Bedeutung der aviären Influenza für das Gesundheitssystem.

Acute febrile respiratory illness in the ICU: reducing disease transmission

Acute febrile respiratory illness (FRI) leading to respiratory failure is a common reason for admission to the ICU. Viral pneumonia constitutes a portion of these cases, and often the viral etiology goes undiagnosed. Emerging viral infectious diseases such as severe acute respiratory syndrome and avian influenza present with acute FRIs progressing to respiratory failure and ARDS. Therefore, early recognition of a viral cause of acute FRI leading to ARDS becomes important for protection of health-care workers (HCWs), lessening spread to other patients, and notification of public health officials. These patients often have longer courses of viral shedding and undergo higher-risk procedures that may potentially generate aerosols, such as intubation, bronchoscopy, bag-valve mask ventilation, noninvasive positive pressure ventilation, and medication nebulization, further illustrating the importance of early detection and isolation. A small number of viral agents lead to acute FRI, respiratory failure, and ARDS: seasonal influenza, avian influenza, coronavirus associated with severe ARDS, respiratory syncytial virus, adenovirus, varicella, human metapneumovirus, and hantavirus. A systematic approach to early isolation, testing for these agents, and public health involvement becomes important in dealing with acute FRI. Ultimately, this approach will lead to improved HCW protection, reduction of transmission to other patients, and prevention of transmission in the community.

A Cross-sectional Study of Primary-care Physicians in Singapore on Their Concerns and Preparedness for an Avian Influenza Outbreak

Introduction: During an avian influenza (AI) pandemic, primary-care physicians (PCPs) are expected to play key roles in the prevention and control of the disease. Different groups of PCPs could have different concerns and preparedness level. We assessed the concerns, perceived impact and preparedness for an outbreak among PCPs in Singapore. Materials and Methods: A cross-sectional survey of PCPs working in private practice (n = 200) and public clinics (n = 205) from March to June 2006 with an anonymous self-administered questionnaire on concerns (12- items), perceived impact (10 items) and preparedness (10 items) for an outbreak. Results: Two hundred and eighty-five PCPs responded – 149 (response rate: 72.7%) public and 136 (response rate: 67.3%) private. The majority were concerned about risk to their health from their occupation (95.0%) and falling ill with AI (89.7%). Most (82.5%) accepted the risk and only 33 (11.8%) would consider stopping work. For perceived impact, most felt that people would avoid them (69.6%) and their families (54.1%). The majority (81.3%) expected an increased workload and feeling more stressed at work (86.9%). For preparedness, 78.7% felt personally prepared for an outbreak. Public PCPs were more likely to be involved in infection-control activities and felt that their workplaces were prepared. Conclusions: Most PCPs felt personally prepared for an outbreak but were concerned about their exposure to AI and falling ill. Other concerns included social ostracism for themselves and their families. Public PCPs appeared to have a higher level of preparation. Addressing concerns and improving level of preparedness are crucial to strengthen the primary-care response for any AI outbreak. Key words: Impact, Bird flu, Planning, Response

Delayed antiviral plus immunomodulator treatment still reduces mortality in mice infected by high inoculum of influenza A/H5N1 virus

The mortality of human infection by influenza A/H5N1 virus can exceed 80%. The high mortality and its poor response to the neuraminidase inhibitor oseltamivir have been attributed to uncontrolled virus-induced cytokine storm. We challenged BALB/c mice with 1,000 LD50 of influenza A/Vietnam/1194/04. Survival, body weight, histopathology, inflammatory markers, viral loads, T lymphocyte counts, and neutralizing antibody response were documented in infected mice treated individually or in combination with zanamvir, celecoxib, gemfibrozil, and mesalazine. To imitate the real-life scenario, treatment was initiated at 48 h after viral challenge. There were significant improvements in survival rate (P = 0.02), survival time (P < 0.02), and inflammatory markers (P < 0.01) in the group treated with a triple combination of zanamivir, celecoxib, and mesalazine when compared with zanamivir alone. Zanamivir with or without immunomodulators reduced viral load to a similar extent. Insignificant prolongation of survival was observed when individual agents were used alone. Significantly higher levels of CD4+ and CD8+ T lymphocytes and less pulmonary inflammation were also found in the group receiving triple therapy. Zanamivir alone reduced viral load but not inflammation and mortality. The survival benefits of adding celecoxib and mesalazine to zanamivir could be caused by their synergistic effects in reducing cytokine dysfunction and preventing apoptosis. Combinations of a neuraminidase inhibitor with these immunomodulators should be considered in randomized controlled treatment trials of patients suffering from H5N1 infection.

Avian influenza viruses in wild birds: a moving target

The long-standing evolutionary and ecological relationships between wild birds and influenza A viruses has created a broad pool of viral genetic diversity and a reservoir of potentially transmissible viruses. An understanding of these relationships can help us identify and modify critical control points to reduce transmission of avian influenza viruses into animal and human populations.

[Bird flu: what the intensivist must know]

In the last century, humankind has faced 3 major pandemics of influenza virus infections. The first one occurred in 1918 and caused a significant amount of deaths. It was also capable of crossing over species barrier and affecting mammals, and most worrisome, humans. Since then several outbreaks have been reported in the Southeast of Asia. Many patients with the flu-like illness have a severe course and the patient develops pneumonia and in some cases multiorgan failure involving liver, kidneys, brain and lungs. Since the virus lacks regulatory control of genetic division it undergoes constant mutations leading to new subtypes and, sometimes, new strains. The only drugs that have shown some protection are oseltamivir and zanamivir. It is crucial to develop effective and non-expensive vaccines to prevent the virus spread and infection not only in humans but in birds too.

Influenza vaccines and vaccination strategies in birds

Although it is well accepted that the present Asian H5N1 panzootic is predominantly an animal health problem, the human health implications and the risk of human pandemic have highlighted the need for more information and collaboration in the field of veterinary and human health. H5 and H7 avian influenza (AI) viruses have the unique property of becoming highly pathogenic (HPAI) during circulation in poultry. Therefore, the final objective of poultry vaccination against AI must be eradication of the virus and the disease. Actually, important differences exist in the control of avian and human influenza viruses. Firstly, unlike human vaccines that must be adapted to the circulating strain to provide adequate protection, avian influenza vaccination provides broader protection against HPAI viruses. Secondly, although clinical protection is the primary goal of human vaccines, poultry vaccination must also stop transmission to achieve efficient control of the disease. This paper addresses these differences by reviewing the current and future influenza vaccines and vaccination strategies in birds.

Healthy human subjects have CD4+ T cells directed against H5N1 influenza virus

It is commonly perceived that the human immune system is naive to the newly emerged H5N1 virus. In contrast, most adults have been exposed to influenza A H1N1 and H3N2 viruses through vaccination or infection. Adults born before 1968 have likely been exposed to H2N2 viruses. We hypothesized that CD4(+) T cells generated in response to H1N1, H3N2, and H2N2 influenza A viruses also recognize H5N1 epitopes. Tetramer-guided epitope mapping and Ag-specific class II tetramers were used to identify H5N1-specific T cell epitopes and detect H5N1-specific T cell responses. Fifteen of 15 healthy subjects tested had robust CD4(+) T cell responses against matrix protein, nucleoprotein, and neuraminidase of the influenza A/Viet Nam/1203/2004 (H5N1) virus. These results are not surprising, because the matrix protein and nucleoprotein of influenza A viruses are conserved while the neuraminidase of the H5N1 virus is of the same subtype as that of the circulating H1N1 influenza strain. However, H5N1 hemagglutinin-reactive CD4(+) T cells were also detected in 14 of 14 subjects examined despite the fact that hemagglutinin is less conserved. Most were cross-reactive to H1, H2, or H3 hemagglutinin epitopes. H5N1-reactive T cells were also detected ex vivo, exhibited a memory phenotype, and were capable of secreting IFN-gamma, TNF-alpha, IL-5, and IL-13. These data demonstrate the presence of H5N1 cross-reactive T cells in healthy Caucasian subjects, implying that exposure to influenza A H1N1, H3N2, or H2N2 viruses through either vaccination or infection may provide partial immunity to the H5N1 virus.

Amantadine and rimantadine for influenza A in children and the elderly

BACKGROUND

Although amantadine (AMT) and rimantadine (RMT) are used to relieve or treat influenza A symptoms in healthy adults, little is known about the effectiveness and safety of these antivirals in preventing and treating influenza A in children and the elderly.

OBJECTIVES

The aim of this review was to systematically consider evidence on the effectiveness and safety of AMT and RMT in preventing and treating influenza A in children and the elderly.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, issue 3); MEDLINE (1966 to July 2007) and EMBASE (1980 to July 2007).

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing AMT and/or RMT in children and the elderly with placebo, control, other antivirals or comparing different doses or schedules of AMT and/or RMT or no intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and assessed methodological quality. Disagreements were resolved by consensus. In all comparisons except for one, the trials in children and in the elderly were analysed separately. Data were analysed and reported using Cochrane Review Manager 4.2. software.

MAIN RESULTS

In children, RMT was effective in the abatement of fever on day three of treatment. AMT showed a prophylactic effect against influenza A infection. AMT and RMT were not related to an increase in the occurrence of adverse effects. RMT also was considered to be well tolerated by the elderly, but showed no prophylactic effect. Different doses were comparable in the prophylaxis of influenza in the elderly, as well as in reporting adverse effects. Zanamivir prevented influenza A more effectively than RMT in the elderly.

AUTHORS' CONCLUSIONS

AMT was effective in the prophylaxis of influenza A in children. As confounding matters might have affected our findings, caution should be taken when considering which patients should to be given this prophylactic. Our conclusions about effectiveness of both antivirals for the treatment of influenza A in children were limited to a proven benefit of RMT in the abatement of fever on day three of treatment. Due to the small number of available studies we could not reach a definitive conclusion on the safety of AMT or the effectiveness of RMT in preventing influenza in children and the elderly.

The role of oseltamivir in the treatment and prevention of influenza in children

The burden of seasonal influenza in children is poorly recognized, in spite of the potential for severe and even life-threatening illness and common secondary complications. Children are a primary reservoir for the spread of influenza to both family members and the community, which imposes a sizeable social and economic strain. Although vaccination is the primary intervention against childhood influenza, the antiviral neuraminidase inhibitors, oseltamivir and zanamivir, provide treatment options. Oseltamivir is administered orally to children aged > 1 year and has been shown to cost-effectively reduce the influenza disease burden and duration of viral shedding. Additionally, oseltamivir postexposure prophylaxis provides protective efficacy for children and families. Oseltamivir has shown excellent tolerability and a low potential for viral resistance in pediatric studies. In the event of an influenza pandemic, oseltamivir is expected to be at the forefront of containment strategies. This article reviews the pharmacology, efficacy and tolerability of oseltamivir as treatment and prophylaxis in children.