INFLUENZA

TIMELINE OF HUMAN FLU PANDEMIC

1918
Pandemic
Spanish flu H1N1
The most devastating flu pandemic in recent history, killing more than 500,000
people in the United States, and 20 million to 50 million people worldwide.
1957-58
Pandemic
"Asian flu" H2N2
First identified in China, this virus caused roughly 70,000 deaths in the United
States during the 1957-58 season. Because this strain has not circulated in humans
since 1968, no one under 30 years old has immunity to this strain.
1968-69
Pandemic
"Hong Kong flu" H3N2
First detected in Hong Kong, this virus caused roughly 34,000 deaths in the United
States during the 1968-69 season. H3N2 viruses still circulate today..
1977
Appearance of a new influenza strain in humans
Russian flu H1N1
Isolated in northern China, this virus was similar to the virus that spread before
1957. For this reason, individuals born before 1957 were generally protected;
however children and young adults born after that year were not because they had
no prior immunity.
2009
H5N1
On January 7, Indonesia confirmed a new case of human infection with H5N1
influenza. Since that time, new cases have been identified in Egypt, China,
Indonesia and Vietnam.

MODE OF TRANSMISSION

Person to Person
o direct contact with an infected individual within 6 feet
o speaking, coughing, sneezing, kissing
o transmitted primarily by droplets or respiratory secretions of infected
persons

Fomites - any object or substance capable of carrying infectious organisms,

such as viruses and bacteria
Examples: door knobs, clothing, money

Animal to Person
o when people's work brings them in contact with infected animals.
o when people contact infected animals during their everyday lives, such
as when visiting live animal markets or when these animals are kept as
part of the household.
o when people handle or slaughter infected animals, or work with raw
meat and by-products from infected animals.
o when people contact things around them, such as animal housing
areas and equipment, ponds and other water sources, faeces, and
feathers, if these things are contaminated with influenza viruses

TYPES/ CLASSIFICATIONS OF INFLUENZA

VIRUS

Influenza Virus A
causes influenza in
birds
and
some mammals,
and
is
the
only species of influenza virus A.
the most virulent human pathogens among the three influenza types
and cause the most severe diseases
Strains of all subtypes of influenza A virus have been isolated from wild
birds, although disease is uncommon. Some isolates of influenza A

virus cause severe disease both in domestic poultry and, rarely, in

humans. Occasionally, viruses are transmitted from wild aquatic birds
to domestic poultry, and this may cause an outbreak or give rise to
human influenza pandemics.
The influenza A virus can be subdivided into different serotypes based
on the antibody response to these viruses. The serotypes that have
been confirmed in humans, ordered by the number of known human
pandemic deaths, are:
H1N1, which caused Spanish Flu in 1918, and Swine Flu in
2009
H2N2, which caused Asian Flu in 1957
H3N2, which caused Hong Kong Flu in 1968
H5N1, which caused Bird Flu in 2004
H7N7, which has unusual zoonotic potential
H1N2, endemic in humans, pigs and birds
H9N2, H7N2, H7N3, H10N7, H7N9

Influenza Virus B
o is a genus in the virus family Orthomyxoviridae
o are only known to infect humans and seals
o Influenza B almost exclusively infects humans and is less common than
influenza A. This type of influenza mutates at a rate 23 times lower
than type A. This reduced rate of antigenic change, combined with its
limited host range ensures that pandemics of influenza B do not occur.
Influenza Virus C
o Influenza C virus, which infects humans, dogs and pigs, sometimes
causing both severe illness and local epidemics. However, influenza C
is less common than the other types and usually only causes mild
disease in children.

MORPHOLOGY

The virion is

pleomorphic;

the

envelope

can

occur

in

spherical and filamentous forms. In general, the virus's

morphology is spherical with particles 50 to 120 nm in
diameter, or filamentous virions 20 nm in diameter
and

200 to 300 (3000) nm long. There are some 500

distinct spike-like surface projections of the envelope
each projecting 10 to 14 nm from the surface with

some types (i.e. hemagglutinin esterase(HEF)) densely dispersed over the surface,
and with others (i.e. hemagglutinin (HA)) spaced widely apart.

The

major glycoprotein (HA)

irregularly

by

is

interposed

clusters

of neuraminidase (NA), with a ratio of HA to

NA of about 45 to 1.
Lipoprotein membranes
the

enclose

nucleocapsids;

nucleoproteins of different size

classes

with a loop at each end; the

arrangement
uncertain.

within
The

the

virion

ribonuclear

is
proteins

are

filamentous and

fall in the range of 50 to 130 nm long and 9 to 15 nm in diameter. They have a

helical symmetry.

DIAGNOSIS OF INFLUENZA
Firm diagnosis is by means of virus isolation and serology. The virus can be
isolated from the nose or a throat swab. This is used to infect cells in culture (or
eggs). Hemadsorption may be used to detect infected cells. Polymerase chain
reaction (PCR) test are being developed to detect viral RNA. Recently, rapid tests
that can be used in a physician's office have been approved. Provisional
diagnosis is often made clinically, based on knowledge of a current outbreak of
influenza combined with appropriate clinical symptoms (fever, cough, runny nose,
malaise).
Laboratory Diagnosis
During epidemics, a presumptive diagnosis can be made on the basis of the clinical
symptoms. However, influenza A and B can co-circulate, and mixed infections of
influenza and other viruses have been reported. Isolated cases of suspected
influenza should be investigated for these may represent the first cases of an
impending epidemic.
1. Rapid Diagnosis - Nasopharyngeal aspirates are the specimens of choice as
they are the most sensitive. However, throat and nasal swabs are more
commonly used given the difficulties involved in taking nasopharyngeal
aspirates.
o

Cells from pathological specimens may be examined for the presence

of influenza A and B antigens by indirect immunofluorescence.
Although many workers are convinced of the value of this technique,

others have been disappointed with the specificity of the antisera and
the level of background fluorescence that makes the test difficult to
interpret. Type specific sera are available that could differentiate
between H3 and H1 viruses. However, they could not differentiate
between the seasonal H1N1 and the 2009 pandemic H1N1.
o

EIA tests for the detection of influenza A viral antigens are available
that are easier to interpret than immunofluorescence since whole cells
are not required. Commercially available tests could not differentiate
between H3N3 and H1N1 influenza.

RT-PCR assays for the detection of influenza RNA are available that
provides the greatest sensitivity and specificity. Moreover, the PCR
product can be sequenced for strain identification and epidemiological
investigation. RT-PCR assays were the only rapid assays available for
the identification of the 2009 pandemic H1N1 virus and proved
invaluable during the pandemic. However, RT-PCR assays are very
expensive and the test had to be rationed once the number of
suspected cases become overwhelming.

2. Virus Isolation - Throat swabs, NPA and nasal washings may be used for
virus isolation. It is reported that nasal washings are the best specimens for
virus isolation. The specimen may be inoculated in embryonated eggs or
tissue culture. 10-12 day embryonated eggs are used for virus isolation. The
specimen is inoculated into the amniotic cavity. The virus replicates in the
cells of the amniotic membrane and large quantities are released back into
the amniotic fluid. After 2-3 days incubation, virus in the amniotic fluid can be
detected by adding aliquots of harvested amniotic fluid to chick, guinea pig,
or human erythrocytes. Pathological specimens can be inoculated on to tissue
cultures of kidney, chicks or a variety of other species. Rhesus monkey cells
are the most sensitive. Although no CPE is produced, newly produced virus
can be recognized by haemadsorption using the cells in the tissue culture,
and haemagglutination using the culture medium which contains free virus
particles. Influenza B virus and occasionally influenza A will produce a CPE in
MDCK cells. Influenza viruses isolated from embryonated eggs or tissue
culture can be identified by serological or molecular methods. Influenza
viruses can be recognized as A, B, or C types by the use of complement
fixation tests against the soluble antigen. (A soluble antigen is found for all
influenza A, B or C type virus but antibody against one type does not cross
react with the soluble antigen of the other. The further classification of
influenza isolates into subtypes and strains is a highly specialized
responsibility of the WHO reference laboratories. The HA type is identified by
HAI tests, the NA type is also identified.

3. Serology - Virus cannot be isolated from all cases of suspected infection.

More commonly, the diagnosis is made retrospectively by the demonstration
of a rise in serum antibody to the infecting virus. CFT is the most common
method used using the type specific soluble antigen. However, the CF test is
thought to have a low specificity. A more specific test is the HAI test. Infection
by influenza viruses results in a rise in serum antibody titre, but the
requirement for a 4-fold or greater rise in titre of HI of CF antibody reflects
the inaccuracy of these tests for detecting smaller increases in antibody. A
more precise method for measuring antibody is by SRH. SRH is more
sensitive than CF or HAI tests and has a greater degree of precision. A 50%
increase in zone area represents a rise in antibody and is evidence of recent
infection. Sera do not have to be pretreated to remove non-specific inhibitors
which plaque the HAI test. SRH may well replace CF and HAI tests in
diagnostic laboratory in future.

SYMPTOMS AND COMPLICATIONS

1. Uncomplicated influenza

Fever (38 - 40 degrees C)

Myalgias, headache

Ocular symptoms - photophobia, tears, ache

Dry cough, nasal discharge

H1N1 strain, the 2009 "swine flu", also gives rise to gastro-intestinal
symptoms (e.g. vomiting, diarrhea)

2. Pulmonary complications:

Croup (acute laryngotracheobronchitis) in young children - symptoms

include cough (like a barking seal), difficulty breathing, stridor (crowing sound
during inspiration)

Primary influenza virus pneumonia

Secondary bacterial infection: This often involves Streptococcus pneumoniae,

Staphylococcus aureus, Hemophilus influenzae

The build up of fluids and lack of mucociliary clearance in the respiratory tract
provide a good environment for bacterial growth.

Complications often occur in patients with underlying chronic obstructive pulmonary

or heart disease. The underlying problems may not have been recognized prior to
the influenza infection.
3. Non-pulmonary complications of influenza:

Myositis - This is rare and more likely to be seen in children after influenza
type B infection

Cardiac complications

Encephalopathy - Increased surveillance of hospital patients less than 21

years of age in the state of Michigan in the United States during the 2002 2003 flu season revealed eight cases of influenza-associated encephalopathy
(figure 6A). Two of these patients (aged two and five years) died. Similar
complications of influenza have been reported from Japan. Even when not
fatal, encephalopathy can have serious sequelae and this emphasizes the
importance of vaccination. Neither of the Michigan fatalities had been
vaccinated.

Reye's syndrome - The effects of influenza virus infection on the liver and
brain are particularly serious. In the liver fatty deposits are seen while in the
brain edema occurs. Reye's syndrome includes vomiting, lethargy and may
result in coma. It is rare, but approximately 40% of cases are fatal. The origin
of Reye's syndrome is unclear but seems to follow certain viral infections
such as influenza or chicken pox (varicella zoster/herpes zoster), especially if
they are in the young and especially if they have been treated with aspirin.
Aspirin is contraindicated for childhood or adolescent fevers because it is a
risk factor in the development Reye's syndrome. Acetaminophen and
Ibuprofen are apparently not associated with Reye's syndrome.

Guillain-Barr syndrome (acute idiopathic polyneuritis) - The cause of

this syndrome in the central nervous system is mysterious. It is an
autoimmune disease that can follow a viral or bacterial (e.g. Campylobacter
jejuni) infection. Recent anti-influenza vaccines do not seem to increase the
risk of developing Guillain-Barre Syndrome.

Following a typical incubation period of 48 hours, the typical symptoms of influenza

appears. The onset is abrupt with a marked fever, headache, photophobia,
shivering, a dry cough, malaise, myalgia, and a dry tickling throat. The fever is
continuous and lasts around 3 days. Influenza B infection is similar to influenza A,
but infection with influenza C is usually subclinical or very mild in nature.
Complications

1. Tracheobronchitis and bronchiolitis - A small proportion of patients

develop more sever respiratory symptoms where rales and rhonchi are heard
but the chest is radiologically clear. These symptoms are more commonly
seen in the elderly and patients with COAD.
2. Pneumonia - primary viral pneumonia or a secondary bacterial pneumonia
may develop. Primary viral pneumonia is relatively uncommon, but cases
have been demonstrated in many influenza epidemics. It may occur in
previously young and healthy persons, but are commonly associated with
patients with preexisting cadiovascular disease such as Rheumatic fever.
Secondary bacterial pneumonia is more common than primary viral
pneumonia. It was speculated that the high incidence of deaths in young
people during the Spanish influenza pandemics of 1917-1918 may have been
due to secondary bacterial pneumonia in a population generally debilitated
by the effects the WWI.
3. Secondary bacterial pneumonia - usually occurs late in the course of
disease, after a period of improvement has been observed for the acute
disease. The symptoms and signs are that of a typical bacterial
pneumonia. S. aureus is most commonly involved although S.
pneumoniae and H. influenzae may be found. There appears to be a good
reason why S. aureus is so commonly found in cases of secondary bacterial
pneumonia. Infection of cells by influenza A requires cleavage of the virus
haemagglutinin by proteases, and some strains of S. aureus produces such
enzymes. Thus S. aureus and influenza may promote infection by the other.
Influenza A by damage to the healthy respiratory epithelium.
4. Myositis and myoglobinuria - In addition to myalgia, which is
characteristic of acute influenza infection, clinical myositis and myoglobinuria
may occur.
5. Reye's syndrome - Reye's syndrome is characterized by encephalopathy
and fatty liver degeneration. The disease has a 50% mortality amongst
hospitalized cases and had been associated with several viruses; such as
influenza A and B, Coxsackie B5, echovirus, HSV, VZV, CMV and adenovirus.
6. Other complications - influenza infection have been implicated in acute
viral encephalitis and Guillain-Barre syndrome. Influenza A was also
associated with the cot death syndrome.

TREATMENT AND PREVENTIVE MEASURES

Chemotherapy

Zanamivir (Relenza) and Oseltamivir (Tamiflu)

Two neuraminidase inhibitors have been approved by the FDA (Zanamivir [Relenza]
and Oseltamivir [Tamiflu]). They are active against both influenza A and influenza B
and can reduce the duration of uncomplicated influenza (by approximately 1day in
about 70-90% of adults) if taken within two days of the onset of illness. However,
oseltamivir resistance has been seen in some circulating strains recently (the 2009
H1N1 strain is sensitive).
To date there are only a few studies of how effective these drugs are in reducing
serious complications in high risk groups when used to treat influenza (as
contrasted with when used prophylactically). Some limited data suggest they may
be beneficial. However, both are approved for prophylaxis as well as treatment.

Rimantadine and amantadine

Rimantadine and amantadine block virus entry across the endosome and also
interfere with virus release (see Anti-viral chemotherapy). They may be given
as protective agents during an outbreak, especially to those at severe risk
and key personnel.

These drugs were widely used. However, in the 2005-2006 influenza season 92% of
the H3N2 strains examined had a mutation which would confer resistance to these
drugs, as did 25% of the H1N1 strains tested - similar problems have been seen in
seasons since then so these drugs are not recommended until the level of
resistance in the major circulating strains drops. In the absence of the resistant
mutations they were good prophylactic agents for influenza A (but not for influenza
B), although there are some problems in taking them on a long term basis. They
could be given to protect during an outbreak - especially those at severe risk and
key personnel. They could also be given at the time of vaccination for a few weeks until the humoral response had time to develop. There is some evidence that
rimantidine and amantadine can reduce the duration of non-resistant influenza A if
given early in infection.

Treatment
Influenza epidemics are responsible for massive disruption to industry, and for a
significant number of deaths, particularly in the elderly and the very young. At
present, treatment of influenza is entirely symptomatic. Salicylates should be
avoided in children because of the link with Reye's syndrome. Neuraminidase
inhibitors, in particular Oseltamivir have replaced Amantidine as the anti-viral drug
of choice in the treatment of influenza infections.

1. Oseltamivir (Tamiflu) - the rational approach to drug design has led to the
design of several potent inhibitors of influenza neuraminidase. Oseltamivir is
now the drug of choice for the treatment of influenza. Unlike zanamivir, it can
be given orally. Like zanamivir, it had been shown to be effective and devoid
of significant side effects in clinical trials. It is approved by the FDA for use as
treatment for influenza A and B in persons 18 years or older. It is also
approved for prophylaxis in persons 13 years or older. Its lack of side effects
would make particularly attractive in a family setting although its higher cost
compared to amantidine and rimantidine should be taken into account. It is
recommended to be given within 48 hours of the onset of symptoms.
Mutations conferring resistance are single amino acid residue substitutions
(His274Tyr) in the neuraminidase enzyme. The resistance to different types
varies enormously year to year. H3N2 strains were mainly sensitive whereas
seasonal H1N1 were almost totally resistant. More than 98% of the 2009
pandemic influenza H1N1 tested were sensitive.
2. Zanamivir - Zanamivir was the first neuraminidase inhibitor available for
clinical use and is effective against both influenza A and B. Because of its
poor bioavailability, zanamivir must be administered by inhalation. Zanamivir
had been shown to be effective and devoid of significant side effects in
clinical trials. It is now approved by the FDA for use as treatment for influenza
A and B in persons 12 years or older but not for prophylaxis. Because it
cannot be given orally, it popularity has been eclipsed by oseltamivir.
3. Amantidine - this compound inhibit the growth of influenza viruses in cell
culture and in experimental animals. Amantidine is only effective against
influenza A, and some naturally occurring strains of influenza A are resistant
to it. The mechanism of action of amantadine is not known. It is thought to
act at the level of virus uncoating. The compound has been shown to have
both therapeutic and prophylactic effects. Amantidine significantly reduced
the duration of fever (51 hours as opposed to 74 hours) and illness. The
compound also conferred 70% protection against influenza A when given
prophylactically. Amantidine can occasionally induce mild neurological
symptoms such as insomnia, loss of concentration and mental disorientation.
However, these symptoms quickly developed in susceptible individuals and
cease when treatment is stopped. The therapeutic and prophylactic activity
of amantidine is now generally accepted and numerous analogues of this
compound have been prepared. Rimantadine is not as effective as
amantadine but is less toxic. Prophylaxis with 200mg of amantadine per day
for 5 to 6 weeks or for the duration of the influenza A outbreak is not
recommended for all persons. However, elderly persons with chronic
underlying disease, institutionalized persons, staff and patients in hospital,
close contacts of an index case, and patients who cannot receive influenza A
vaccine due to sensitivity to egg protein may benefit from prophylaxis.

Amantadine can also be used for therapy of uncomplicated influenza A

infections. The recommended dose is 200mg for 5 days. Rimantadine may be
used in place of amantadine for prophylaxis and the treatment of
uncomplicated influenza A infections.
4. Rimantidine - this compound is similar to amantidine but has fewer side
effects. It is approved by the FDA for the treatment and prophylaxis of
influenza A infection in persons one year or older. It should be used for
uncomplicated influenza A infections only since it is thought to be less
effective than amantidine. Amantadine and rimantadine resistant viruses are
readily generated in the laboratory. Resistance has been linked to changes in
the M2 protein. To date, the emergence of resistant influenza A has been
documented primarily in young children undergoing therapy with
rimantadine. The resistant viruses had been transmitted and caused
influenza. The universal susceptibility of all types of naturally occuring
influenza A isolated from man and animals suggests that resistance will be
found only in individuals treated with the drug. The reason for the natural
selection of the susceptible phenotype of influenza A in nature is not known.