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Avian Influenza A (H5N1)

viruses among birds continues to

cause human disease with
high mortality and to pose the
threat of a pandemic
Patients with confirmed Influenza A
(H5N1) illness

Writing Committee of the Second World Health Organization Consultation on Clinical Aspects
of Human Infection with Avian Influenza A (H5N1) Virus. N Engl J Med 2008;358:261-273
 According to the
World Health Organization (WHO), a
pandemic can start when three
conditions have been met:

 the emergence of a disease new to the population.

 the agent infects humans, causing serious illness.
 the agent spreads easily and sustainably among

 The Influenza of 1918


 In epizoology, an epizootic (from

Greek epi- upon + zoion animal) is a
disease that appears as;

new cases in a given animal

population, during a given period, at
a rate that substantially exceeds
what is "expected" based on recent
experience (i.e. a sharp elevation in
the incidence rate).

 High population density is a major

Published online 6 january, 2008

The Journal of Immunology
 E-
pub (www.jimmunol.org)

Published online 6
January 2008
Nature Biotechnology
Influenza virus particles mostly
spherical/ovoid, 80-120nm diameter

 The outer surface of the

particle consists of a lipid
envelope-which project two
types of
 glycoprotein
spikes :

 haemagglutinin (HA), a
135Å trimer
 neuraminidase (NA), a 60Å
Paul Digard, Dept of
University of Cambridge
Host Range
Species barrier between birds
and human:
PB2, PB1
and PA


Hemaggluti Neuraminid M
nin ase 2

Determine species
specificity for
avian α 2,3 –linked or
human α 2,6 –linked sialic
Epidemiology of Human

 Incidence and Demographic


 Transmission
 Handling of dead and sick poultry during the
week before the onset of illness –

 Consuming raw or uncooked poultry

 Incubation Period
2-5 days

If happened human –to -human transmission

it could be 3-5 days or 8-9 days.
Incidence and Demographic

 Influenza A (H5N1) disease in

human is very rare.
 Number of confirmed cases of H5N1 virus infection is 340 as of Dec 14
th , 2007.

 Increases in human cases of H5N1 have been observed during cooler months.

Infection rate and case fatality is more prevalent among younger individual ( age 40 or below )

compare to older individual ( 50 yrs of age or older)

How age can be a factor for the ability of

the virus to infect and cause fatality ?
Whether preexisting immunity and
exposure could contribute ?

Probably Yes
 Healthy Human Subjects Have CD4 T
Cells Directed Against
 H5N1 Influenza Virus

Michelle Roti,* Junbao Yang,* DeAnna Berger,* Laurie

Huston,* Eddie A. James,*and William W. Kwok2*†
Human immune system is naïve to the
newly emerged H5N1 virus

Most adults immune system are

acquainted with H1N1 and H3N2 viruses
through vaccination or infection

Adult born before 1968 have likely been

exposed to H2N2 virus

CD4+T cells generated in response to

H1N1, H3N2 and H2N2 influenza A
viruses also recognize H5N1 epitopes-

Immunological memory
Immunological memory
- After infection
(antigen) is cleared
majority of effector
cells die by apoptosis
(programmed cell death).
- However, a significant
number persist as
memory cells –
- Immunological
memory ensures
rapid response on a
second encounter
with a pathogen, and
thereby usually
Viral Factors

Viral Replication
•Bronchiolar and alveolar cells, upper and
lower respiratory track
•Viral RNA persists in the respiratory track
upto 3 months
Pathological Findings
•Diffuse alveolar damage, inflammatory cells
and apoptosis in alveolar cells
Host Responses
•Increased level of imflammatory
cytokines IFN-γ, TNF-α, IL-5,IL-13.
H5N1 binds to α2,3-linked sialic acid
receptor on avian cells

lls et
ce rg



H5N1 virus can acquire mutations that permit

binding to both α 2,3-linked sialic acid receptor
and α2,6-linked sialic acid receptor
Changes in multiple viral genes are probably
required to generate a potentially pandemic
Now the question arises how H5N1
can cause infection in human ?

 A switch in specificity of H5N1

hemagglutinin (HA) from avian like
(α2-3-linked sialyated glycans
) to human- like (α2-6 sialyated
glycans) receptors is believed to be
associated with their adaptation to
infect human
Glycan topology determines human
adaptation of avian H5N1 virus
hemagglutinin :

 a characteristic structural topology—and

not the a2-6 linkage itself—enables
specific binding of HA to a2-6 sialylated

 recognition of this topology may be

critical for adaptation of HA to bind
glycans in the upper respiratory tract of
Why H5N1 viruses have not yet
gained a foothold in the human

 An integrated
analytical and data
mining approach demonstrates
that from the human-adapted H1N1
and H3N2 viruses, but not H5N1 (bird
flu) viruses, specifically bind to long
α2-6 sialylated glycans with this
features Severe pneumonia/
Acute respiratory distress
Other syndromes (listed in the
Laboratory diagnostic

• Initial diagnosis by Real –time PCR

( from nasal swab, throat swab)
• Hemagglitination-inhibition
assay/microneutralization assay—
labor –intensive and require BSL3
 Antiviral agents
 Oseltamivir Synthetic sialic acid
 Zanamivir analogues

 Amantadine Block membrane

 Rimantadine

 Combined Oseltamivir and

Immune suppression
-adverse effect of steroid

Increased Virus threat

 increasing open trade in food

/ animal products / pets
 faster human transportation
in the shrinking world
 species jump
Viruses listed as threat

Human deficiency virus (from Africa)

From chimpanzee or other non human

West Nile Virus (WNV) (from the middle

From birds via mosquitoes

H5N1 avian influenza virus (from east Asia

From birds directly

• SARS( Severe acute respiratory

syndrome virus )(from Guangdong