Mutational antigenic landscape of prevailing H9N2 influenza virus hemagglutinin spectrum

Clade 2.3.4.4b highly pathogenic H5N1 influenza viruses from birds in China replicate effectively in bovine cells and pose potential public health risk

In February 2024, H5N1 highly pathogenic avian influenza viruses (HPAIVs) of clade 2.3.4.4b were first reported in dairy cows in the USA. Subsequent multiple outbreaks on dairy farms and sporadic human infections have raised substantial public health concerns. In the same year, four H5N1 HPAIVs of clade 2.3.4.4b were isolated from ducks and geese in live poultry markets (LPMs) spanning seven provinces in China. Evolutionary analysis demonstrated that these viruses had undergone two genetic reassortments with H5 influenza viruses from wild birds in different countries. Except for 565/H5N1, the other three viruses exhibited over 99% genetic homology with avian-origin H5N1 HPAIVs from South Korea and Japan. Notably, 571/H5N1 demonstrated high replication efficiency in bovine-derived cells, particularly in bovine mammary epithelial (MAC-T) cells, and caused 16.7% (1/6) mortality in mice at a dose of 105 EID50/50 μL, indicating its zoonotic potential. Given the potential cross-species transmission risk of H5N1 HPAIVs to cattle herds, we collected 228 serum samples from 12 cattle farms across five provinces and conducted serological testing to investigate seroprevalence of H5N1 HPAIVs in Chinese cattle herds. All tested samples were negative, indicating no widespread infection in the sampled cattle populations. However, infections in cattle from other regions cannot be ruled out. Nevertheless, due to the high mutability of H5N1 HPAIVs, enhanced surveillance of avian influenza viruses is critical to ensure timely responses to potential outbreaks.

Epitope-Optimized Influenza Hemagglutinin Nanoparticle Vaccine Provides Broad Cross-Reactive Immunity against H9N2 Influenza Virus

The H9N2 avian influenza virus (AIV) represents a growing threat to the global poultry industry and poses an ongoing risk of human infections. Vaccination is a crucial strategy for the prevention and control of H9N2 AIVs. However, the continuous evolution of the virus consistently challenges the immune protection efficiency. Therefore, developing a universal H9N2 influenza vaccine capable of eliciting a broad-spectrum immune response is essential for epidemic prevention and control. In this study, we report an epitope-optimized nanoparticle (NPs) vaccine that elicits broad cross-reactive immunity against the H9N2 influenza virus. Utilizing Epigraph, a computational algorithm, we first designed three globular heads of H9 hemagglutinin (HA1) with optimized epitopes. Each antigen was subsequently conjugated to mi3 NPs, and the three constructs were mixed at equimolar ratios to generate the Epigraph vaccine. We compared the Epigraph vaccine to the currently recommended candidate vaccine virus (CVV), AL/39. The Epigraph vaccine effectively induced cross-reactive antibodies in mice and activated both CD4+ and CD8+ T cell immune responses. Moreover, it provided effective protection against lethal challenges of diverse H9N2 strains and significantly reduced the viral load in the lungs of the mice. This study provides a promising universal vaccine candidate for combating future H9N2 epidemics.

Impact of inactivated vaccine on transmission and evolution of H9N2 avian influenza virus in chickens

H9N2 avian influenza virus (AIV) is endemic in poultry worldwide and increasingly zoonotic. Despite the long-term widespread use of inactivated vaccines, H9N2 AIVs remain dominant in chicken flocks. We demonstrated that inactivated vaccines did not prevent the replication of H9N2 AIVs in the upper airway of vaccinated chickens. Viral transmission was enhanced during sequential passage in vaccinated chickens, which was attributed to the restricted production of defective interfering particles and the introduction of stable mutations (NP-N417D, M1-V219I, and NS1-R140W) which enhanced viral replication. Notably, the genetic diversity of H9N2 AIVs was greater and included more potential mammal/human-adapted mutations after passage through vaccinated chickens than through naïve chickens, which might facilitate the emergence of mammal-adapted strains. By contrast, vaccines inducing cellular/mucosal immunity in the upper respiratory tract effectively limit H9N2 AIV. These findings highlight the limitations of inactivated vaccines and the need for revised vaccination strategies to control H9N2 AIV.

Identification & genetic & virological characterisation of a human case of avian influenza A (H9N2) virus from Eastern India

Background & objectives A three-year-old male child from West Bengal, India, with severe acute respiratory symptoms, was confirmed in the laboratory with LPAI H9N2 virus infection under the Indian Council of Medical Research (ICMR) - Pan India Acute Respiratory Infections (ARI) / Severe Acute Respiratory Infections (SARI) surveillance through the Virus Research and Diagnostic Laboratories network. Methods Common respiratory viruses were detected by real-time PCR, followed by subtyping of Influenza A for seasonal and avian viruses. The identified H9N2 virus was isolated and further characterised, including whole genome sequencing. Antibody response was performed in serum samples of the case and family members. Results Complete genome sequencing revealed a G1 lineage (Middle East B sub-lineage). Bayesian evolutionary analyses of the HA gene of Indian H9N2 poultry strains showed three clusters of multiple introductions at the estimated node age of 1999 based on the Human strain A/India/NIV/1519/2024(H9N2) and the other poultry viruses from India evolved with 4.49 × 10-3 substitutions per site per year. The isolated H9N2 virus showed a high EID50 titre of 108.25/200 µl with avian-type receptor specificity. The antibodies against the H9N2 virus were only detected in the study case and not in close contacts confirming limited human-to-human transmission. The virus was found to be sensitive to neuraminidase inhibitors oseltamivir and zanamivir. Interpretation & conclusions Systematic avian influenza surveillance in both birds and humans is required for the early detection of newly evolved viruses.

TRPM2 deficiency ameliorated H9N2 influenza virus-induced acute lung injury in mice

Oxidative stress is involved in lung damage induced by the influenza virus. The transient receptor potential melastatin-2 (TRPM2) cation channel, a Ca2+ permeable non-selective cation channel, is implicated in the mediation of multiple tissue injuries induced by oxidative stress. The role of TRPM2 in several diseases has been widely studied, but there have been few studies on the involvement of TRPM2 in lung injury induced by the H9N2 influenza virus. We investigated the effects of TRPM2 on pathological alterations, oxidative stress, apoptosis, and inflammation in mice infected with H9N2 virus. TRPM2 knockout (TRPM2-/-) mice and wild-type (WT) mice were infected separately with H9N2 influenza virus. Pulmonary oedema, lung permeability, Ca2+ concentration, redox imbalance, apoptosis, and levels of inflammatory factors (IL-1β, IL-6, TNF-α) were increased in WT mice infected with H9N2 virus. However, these effects were diminished by TRPM2 knockout. Our results emphasised the significance of TRPM2 knockdown in mitigating pathological lung alterations, maintaining Ca2+ homeostasis, reducing oxidative damage, preventing apoptosis, and suppressing the production of inflammatory cytokines in H9N2 virus-infected mice. Therefore, inhibition of TRPM2 activation is a potentially important therapeutic strategy for treating lung injury.

The H5N6 Virus Containing Internal Genes From H9N2 Exhibits Enhanced Pathogenicity and Transmissibility

The H5N6 avian influenza virus (AIV) is constantly undergoing recombination and evolution with other subtypes of AIV, resulting in various types of recombinant H5N6 viruses. However, the risk to human public health of different recombinant types of H5N6 viruses remains unclear. Recently, two types of different recombinant H5N6 viruses were isolated from chickens. One of the viruses possessed six internal genes originating from H9N2, named A/Chicken/Hubei/112/2020 (H5N6) (abbreviated 112); the other virus possessed PB2, PB1, PA, and NP originating from H5N1, while the M and NS genes were derived from H9N2, named A/Chicken/Hubei/125/2020 (H5N6) (abbreviated 125). Here, we investigated the receptor binding properties, pathogenicity, and transmissibility of the two H5N6 AIVs. The results showed that 112 and 125 could bind α-2,3-linked sialic acid receptor (avian-like receptor) and α-2,6-linked sialic acid receptor (human-like receptor). However, 125 and 112 showed different pathogenicity in mice. Mice infected with 125 lost only a slight body weight and all survived, while mice infected with 112 lost weight rapidly and all died within a week of infection. Furthermore, in the transmission experiment, 125 could only transmit through direct contact, while 112 could transmit not only by direct contact but also by aerosol. The above results indicated that 112 exhibited enhanced pathogenicity and transmissibility compared to 125, suggesting that the H5N6 virus, whose internal genes were derived from H9N2, could pose a greater threat to human health. Therefore, continuous monitoring of different recombinant H5N6 viruses in poultry should be carried out to prevent their transmission to humans.

Construction with recombinant epitope-expressing baculovirus enhances protective effects of inactivated H9N2 vaccine against heterologous virus

Although the use of inactivated vaccines has kept avian influenza (AI) outbreaks largely under control, they fail to prevent virus shedding. To enhance the efficacy of inactivated H9N2 AIV vaccines (InV), we constructed a multi-epitope recombinant baculovirus (BV-BNT) containing two B cell epitopes and nine T cell epitopes of H9N2 AIV for combined immunization with InV. The results showed that HI titer, IgG and IgM levels, and the percentage of B cells, CD4+ T cells, CD8+ T cells, and CD4+CD8+ T cells were significantly higher in the InV+BV-BNT immunization group than the InV immunization group. Besides, the expression levels of IL-1β, IFN-γ, IFN-α, IL-4, IL-13, and CXCLi1 were significantly higher in the InV+BV-BNT group than the InV group. Moreover, four conservative peptides (NP182-190, NP455-463, NS198-106, and NP380-393) significantly stimulated splenocytes to express IFN-γ in the InV+BV-BNT group instead of InV group. After heterologous virus challenging, the percentages of CD4+ T and CD8+ T cells were significantly upregulated in the InV+BV-BNT group compared to Inv group at 3 DPI. Viral loads in oropharyngeal of the InV+BV-BNT group was significantly lower than that in the InV group at 3 days post-infection (DPI). Furthermore, compared to the InV group, the virus positivity rate of oropharyngeal and cloacal swabs in the InV+BV-BNT group was lower at 5 DPI, with none positive at 7 DPI. Hence, this study indicated that the combined immunization of InV and BV-BNT could induce stronger humoral and cellular immune responses, shorten the detoxification period and reduce viral load compared to Inv alone, which suggests BV-BNT could act as a supplementary vaccine to potentially address the protection deficiency of the H9N2 inactivated vaccine.

Origin, spread, and interspecies transmission of a dominant genotype of BJ/94 lineage H9N2 avian influenza viruses with increased threat

The H9N2 subtype of avian influenza viruses (AIVs) is widely prevalent in poultry and wild birds globally, with occasional transmission to humans. In comparison to other H9N2 lineages, the BJ/94 lineage has raised more public health concerns; however, its evolutionary dynamics and transmission patterns remain poorly understood. In this study, we demonstrate that over three decades (1994-2023), BJ/94 lineage has undergone substantial expansion in its geographical distribution, interspecies transmission, and viral reassortment with other AIV subtypes, increasing associated public health risks. These changes were primarily driven by the emergence of a dominant genotype G57. In the first decade, G57 emerged in East China and rapidly adapted to chickens and spread across China. Since 2013, the G57 genotype has expanded beyond China into eight other countries and reassorted with various AIV subtypes to form new zoonotic reassortants. Chickens have played a key role in the generation and circulation of the G57 viruses, with ducks and other poultry species likely assuming an increasingly importantly role. Over the past decade, G57 has been more frequently detected in wild birds, mammals, and humans. Additionally, Vietnam has emerged as a new hotspot for the international spread of G57. Our results suggest that the BJ/94 lineage H9N2 virus may continue to overcome geographical and species barriers, with potentially more severe consequences.

Recombinant Marek's disease virus type 1 provides full protection against H9N2 influenza A virus in chickens

The H9N2 subtype of the avian influenza virus (AIV) poses a significant threat to the poultry industry and human health. Recombinant vaccines are the preferred method of controlling H9N2 AIV, and Marek's disease virus (MDV) is the ideal vector for recombinant vaccines. During this study, we constructed two recombinant MDV type 1 strains that carry the hemagglutinin (HA) gene of AIV to provide dual protection against both AIV and MDV. To assess the effects of different MDV insertion sites on the protective efficacy of H9N2 AIV, the HA gene of H9N2 AIV was inserted in UL41 and US2 of the MDV type 1 vector backbone to obtain recombinant viruses rMDV-UL41/HA and rMDV-US2/HA, respectively. An indirect immunofluorescence assay showed sustained expression of HA protein in both recombinant viruses. Additionally, the insertion of the HA gene in UL41 and US2 did not affect MDV replication in cell cultures. After immunization of specific pathogen-free chickens, although both the rMDV-UL41/HA and rMDV-US2/HA groups exhibited similar levels of hemagglutination inhibition antibody titers, only the rMDV-UL41/HA group provided complete protection against the H9N2 AIV challenge, and also offered complete protection against challenge with MDV. These results demonstrated that rMDV-UL41/HA could be used as a promising bivalent vaccine strain against both H9N2 avian influenza and Marek's disease in chickens.

European Food Safety Authority, European Centre for Disease Prevention and Control, European Union Reference Laboratory for Avian Influenza, Alexakis L, Buczkowski H, Ducatez M, Fusaro A, Gonzales JL, Kuiken T, Ståhl K, Staubach C, Svartström O, Terregino C, Willgert K, Delacourt R, Kohnle L. Avian influenza overview June-September 2024

Between 15 June and 20 September 2024, 75 highly pathogenic avian influenza (HPAI) A(H5) and A(H7) virus detections were reported in domestic (16) and wild (59) birds across 11 countries in Europe. Although the overall number of detections in Europe continued to be low compared to previous epidemiological years, an increase in cases along the Atlantic, North Sea and Baltic coasts was notable, particularly an increase in the detection of HPAI viruses in colony-breeding seabirds. Besides EA-2022-BB and other circulating genotypes, these detections also included EA-2023-DT, a new genotype that may transmit more efficiently among gulls. In Germany, HPAI A(H7N5) virus emerged in a poultry establishment near the border with the Netherlands. No new HPAI virus detections in mammals were reported in Europe during this period, but the number of reportedly affected dairy cattle establishments in the United States of America (USA) rose to >230 in 14 states, and HPAI virus was identified in three new mammal species. Between 21 June and 20 September 2024, 19 new human cases with avian influenza virus infection were reported from the USA (six A(H5N1) cases and five A(H5) cases), Cambodia (five A(H5N1) cases, including one fatal), China (one fatal A(H5N6) case and one A(H9N2) case), and Ghana (one A(H9N2) case). Most of the human cases (90%, n = 17/19) had reported exposure to poultry, live poultry markets, or dairy cattle prior to avian influenza virus detection or onset of illness. Human infections with avian influenza viruses remain rare and no evidence of human-to-human transmission has been documented in the reporting period. The risk of infection with currently circulating avian A(H5) influenza viruses of clade 2.3.4.4b in Europe remains low for the general public in the European Union/European Economic Area (EU/EEA). The risk of infection remains low-to-moderate for those occupationally or otherwise exposed to infected animals or contaminated environments.

Pathogenicity and transmission of novel highly pathogenic H7N2 variants originating from H7N9 avian influenza viruses in chickens

The H7 subtype avian influenza viruses are circulating widely worldwide, causing significant economic losses to the poultry industry and posing a serious threat to human health. In 2019, H7N2 and H7N9 co-circulated in Chinese poultry, yet the risk of H7N2 remained unclear. We isolated and sequenced four H7N2 viruses from chickens, revealing them as novel reassortants with H7N9-derived HA, M, NS genes and H9N2-derived PB2, PB1, PA,NP, NA genes. To further explore the key segment of pathogenicity, H7N2-H7N9NA and H7N2-H9N2HA single-substitution were constructed. Pathogenicity study showed H7N2 isolates to be highly pathogenic in chickens, with H7N2-H7N9NA slightly weaker than H7N2-Wild type. Transcriptomic analysis suggested that H7N9-derived HA genes primarily drove the high pathogenicity of H7N2 isolates, eliciting a strong inflammatory response. These findings underscored the increased threat posed by reassorted H7N2 viruses to chickens, emphasizing the necessity of long-term monitoring of H7 subtype avian influenza viruses.

The amino acid variation at hemagglutinin sites 145, 153, 164 and 200 modulate antigenicity andreplication of H9N2 avian influenza virus

H9N2 avian influenza virus (AIV), one of the predominant subtypes circulating in the poultry industry, inflicts substantial economic damage. Mutations in the hemagglutinin (HA) and neuraminidase (NA) proteins of H9N2 frequently alter viral antigenicity and replication. In this paper, we analyzed the HA genetic sequences and antigenic properties of 26 H9N2 isolates obtained from chickens in China between 2012 and 2019. The results showed that these H9N2 viruses all belonged to h9.4.2.5, and were divided into two clades. We assessed the impact of amino acid substitutions at HA sites 145, 149, 153, 164, 167, 168, and 200 on antigenicity, and found that a mutation at site 164 significantly modified antigenic characteristics. Amino acid variations at sites 145, 153, 164 and 200 affected virus's hemagglutination and the growth kinetics in mammalian cells. These results underscore the critical need for ongoing surveillance of the H9N2 virus and provide valuable insights for vaccine development.

Continued evolution of H10N3 influenza virus with adaptive mutations poses an increased threat to mammals

The H10 subtype avian influenza virus (AIV) poses an ongoing threat to both birds and humans. Notably, fatal human cases of H10N3 and H10N8 infections have drawn public attention. In 2022, we isolated two H10N3 viruses (A/chicken/Shandong/0101/2022 and A/chicken/Shandong/0603/2022) from diseased chickens in China. Genome analysis revealed that these viruses were genetically associated with human-origin H10N3 virus, with internal genes originating from local H9N2 viruses. Compared to the H10N8 virus (A/chicken/Jiangxi/102/2013), the H10N3 viruses exhibited enhanced thermostability, increased viral release from erythrocytes, and accumulation of hemagglutinin (HA) protein. Additionally, we evaluated the pathogenicity of both H10N3 and H10N8 viruses in mice. We found that viral titers could be detected in the lungs and nasal turbinates of mice infected with the two H10N3 viruses, whereas H10N8 virus titers were detectable in the lungs and brains of mice. Notably, the proportion of double HA Q222R and G228S mutations in H10N3 viruses has increased since 2019. However, the functional roles of the Q222R and G228S double mutations in the HA gene of H10N3 viruses remain unknown and warrant further investigation. Our study highlights the potential public health risk posed by the H10N3 virus. A spillover event of AIV to humans could be a foretaste of a looming pandemic. Therefore, it is imperative to continuously monitor the evolution of the H10N3 influenza virus to ensure targeted prevention and control measures against influenza outbreaks.

Recombinant Hemagglutinin Protein from H9N2 Avian Influenza Virus Exerts Good Immune Effects in Mice

The H9N2 subtype of avian influenza virus (AIV) causes enormous economic losses and poses a significant threat to public health; the development of vaccines against avian influenza is ongoing. To study the immunogenicity of hemagglutinin (HA) protein, we constructed a recombinant pET-32a-HA plasmid, induced HA protein expression with isopropyl β-D-1-thiogalactopyranoside (IPTG), verified it by SDS-PAGE and Western blotting, and determined the sensitivity of the recombinant protein to acid and heat. Subsequently, mice were immunized with the purified HA protein, and the immunization effect was evaluated according to the hemagglutination inhibition (HI) titer, serum IgG antibody titer, and cytokine secretion level of the mice. The results showed that the molecular weight of the HA protein was approximately 84 kDa, and the protein existed in both soluble and insoluble forms; in addition, the HA protein exhibited good acid and thermal stability, the HI antibody titer reached 6 log2-8 log2, and the IgG-binding antibody titer was 1:1,000,000. Moreover, the levels of IL-2, IL-4, and IL-5 in the immunized mouse spleen cells were significantly increased compared with those in the control group. However, the levels of IL-1β, IL-6, IL-13, IFN-γ, IL-18, TNF-α, and GM-CSF were decreased in the immunized group. The recombinant HA protein utilized in this study exhibited good stability and exerted beneficial immune effects, providing a theoretical basis for further research on influenza vaccines.

European Food Safety Authority, European Centre for Disease Prevention and Control, European Union Reference Laboratory for Avian Influenza, Alexakis L, Fusaro A, Kuiken T, Mirinavičiūtė G, Ståhl K, Staubach C, Svartström O, Terregino C, Willgert K, Delacourt R, Goudjihounde SM, Grant M, Tampach S, Kohnle L. Avian influenza overview March-June 2024

Between 16 March and 14 June 2024, 42 highly pathogenic avian influenza (HPAI) A(H5) virus detections were reported in domestic (15) and wild (27) birds across 13 countries in Europe. Although the overall number of detections in Europe has not been this low since the 2019-2020 epidemiological year, HPAI viruses continue to circulate at a very low level. Most detections in poultry were due to indirect contact with wild birds, but there was also secondary spread. Outside Europe, the HPAI situation intensified particularly in the USA, where a new A(H5N1) virus genotype (B3.13) has been identified in >130 dairy herds in 12 states. Infection in cattle appears to be centred on the udder, with milk from infected animals showing high viral loads and representing a new vehicle of transmission. Apart from cattle, HPAI viruses were identified in two other mammal species (alpaca and walrus) for the first time. Between 13 March and 20 June 2024, 14 new human cases with avian influenza virus infection were reported from Vietnam (one A(H5N1), one A(H9N2)), Australia (with travel history to India, one A(H5N1)), USA (three A(H5N1)), China (two A(H5N6), three A(H9N2), one A(H10N3)), India (one A(H9N2)), and Mexico (one fatal A(H5N2) case). The latter case was the first laboratory-confirmed human infection with avian influenza virus subtype A(H5N2). Most of the human cases had reported exposure to poultry, live poultry markets, or dairy cattle prior to avian influenza virus detection or onset of illness. Human infections with avian influenza viruses remain rare and no human-to-human transmission has been observed. The risk of infection with currently circulating avian A(H5) influenza viruses of clade 2.3.4.4b in Europe remains low for the general public in the EU/EEA. The risk of infection remains low-to-moderate for those occupationally or otherwise exposed to infected animals or contaminated environments.

Diversity of genotypes and pathogenicity of H9N2 avian influenza virus derived from wild bird and domestic poultry

Introduction

The H9N2 subtype is a predominant avian influenza virus (AIV) circulating in Chinese poultry, forming various genotypes (A-W) based on gene segment origins. This study aims to investigate the genotypic distribution and pathogenic characteristics of H9N2 isolates from wild birds and domestic poultry in Yunnan Province, China.

Methods

Eleven H9N2 strains were isolated from fecal samples of overwintering wild birds and proximate domestic poultry in Yunnan, including four from common cranes (Grus grus), two from bar-headed geese (Anser indicus), and five from domestic poultry (Gallus gallus). Phylogenetic analysis was conducted to determine the genotypes, and representative strains were inoculated into Yunnan mallard ducks to assess pathogenicity.

Results

Phylogenetic analysis revealed that five isolates from domestic birds and one from a bar-headed goose belong to genotype S, while the remaining five isolates from wild birds belong to genotype A. These bird-derived strains possess deletions in the stalk domain of NA protein and the N166D mutation of HA protein, typical of poultry strains. Genotype S H9N2 demonstrated oropharyngeal shedding, while genotype A H9N2 exhibited cloacal shedding and high viral loads in the duodenum. Both strains caused significant pathological injuries, with genotype S inducing more severe damage to the thymus and spleen, while genotype A caused duodenal muscle layer rupture.

Discussion

These findings suggest that at least two genotypes of H9N2 are currently circulating in Yunnan, and Yunnan mallard ducks potentially act as intermediaries in interspecies transmission. These insights highlight the importance of analyzing the current epidemiological transmission characteristics of H9N2 among wild and domestic birds in China.

European Food Safety Authority, European Centre for Disease Prevention and Control, European Union Reference Laboratory for Avian Influenza, Fusaro A, Gonzales JL, Kuiken T, Mirinavičiūtė G, Niqueux É, Ståhl K, Staubach C, Svartström O, Terregino C, Willgert K, Baldinelli F, Delacourt R, Georganas A, Kohnle L. Avian influenza overview December 2023-March 2024

Between 2 December 2023 and 15 March 2024, highly pathogenic avian influenza (HPAI) A(H5) outbreaks were reported in domestic (227) and wild (414) birds across 26 countries in Europe. Compared to previous years, although still widespread, the overall number of HPAI virus detections in birds was significantly lower, among other reasons, possibly due to some level of flock immunity in previously affected wild bird species, resulting in reduced contamination of the environment, and a different composition of circulating A(H5N1) genotypes. Most HPAI outbreaks reported in poultry were primary outbreaks following the introduction of the virus by wild birds. Outside Europe, the majority of outbreaks in poultry were still clustered in North America, while the spread of A(H5) to more naïve wild bird populations on mainland Antarctica is of particular concern. For mammals, A(H5N5) was reported for the first time in Europe, while goat kids in the United States of America represented the first natural A(H5N1) infection in ruminants. Since the last report and as of 12 March 2024, five human avian influenza A(H5N1) infections, including one death, three of which were clade 2.3.2.1c viruses, have been reported by Cambodia. China has reported two human infections, including one fatal case, with avian influenza A(H5N6), four human infections with avian influenza A(H9N2) and one fatal case with co-infection of seasonal influenza A(H3N2) and avian influenza A(H10N5). The latter case was the first documented human infection with avian influenza A(H10N5). Human infections with avian influenza remain rare and no sustained human-to-human infection has been observed. The risk of infection with currently circulating avian H5 influenza viruses of clade 2.3.4.4b in Europe remains low for the general population in the EU/EEA. The risk of infection remains low to moderate for those occupationally or otherwise exposed to infected animals.