Transmission of influenza virus via aerosols and fomites in the guinea pig model

A new epidemic model with indirect transmission

We consider an epidemic model in which all disease transmission is through shedding of virus by infectives and acquisition by susceptibles, rather than by direct contact. This leads to an susceptible-infectious-virus-removed (SIVR) model for which we can determine the basic reproduction number and the final size relation. We extend the model to an age of infection model with virus shedding a function of the age of infection.

Influenza in children

PURPOSE OF REVIEW

We review the current information and evidence available on the global burden of disease in the pediatric population, clinical presentation and complications, testing, treatment, and immunization.

RECENT FINDINGS

In addition to multiple other risk factors for influenza complications, children with neurologic and neuromuscular disorders are significantly higher risk for serious complications. In practice, there is no lower age limit for children with influenza who can be treated with oseltamivir. The quadrivalent live attenuated influenza vaccine was not recommended for use during the 2016-2017 season due to poor effectiveness.

SUMMARY

Influenza infection causes a significant burden of disease each year in the pediatric population worldwide. Both healthy and chronically ill children can fall prey to complications either due to the virus itself or secondary bacterial infection. Children within high-risk groups should be tested and treated with neuraminidase inhibitors. Immunization against influenza is well tolerated and effective.

Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis

The goal of this review was to examine the effectiveness of personal protective measures in preventing pandemic influenza transmission in human populations. We collected primary studies from Medline, Embase, PubMed, Cochrane Library, CINAHL and grey literature. Where appropriate, random effects meta-analyses were conducted using inverse variance statistical calculations. Meta-analyses suggest that regular hand hygiene provided a significant protective effect (OR=0.62; 95% CI 0.52-0.73; I²=0%), and facemask use provided a non-significant protective effect (OR=0.53; 95% CI 0.16-1.71; I²=48%) against 2009 pandemic influenza infection. These interventions may therefore be effective at limiting transmission during future pandemics. PROSPERO Registration: 42016039896.

Characterization of Viral Exposures in United States Occupational Environments

Viruses are considered to be the most abundant biological particles and have the capability to infect all forms of life leading to a variety of diseases. American workers in specific occupational environments are threatened by viral exposures, highlighting the importance to recognize the type and risk of exposure, as well as the preventive measures that can be taken to reduce the risk of exposure. For example, healthcare workers can potentially be exposed to air and blood-borne pathogens, such as hepatitis and the human immunodeficiency virus. These types of exposures have led to the development of preventive equipment and regulations intended to reduce viral exposures in occupational settings. This chapter will discuss the characteristics of viruses and the occupationally relevant viruses of which people in varying occupations can potentially encounter. Regulatory guidelines and protective strategies will also be reviewed.

New global viral threats

Infectious diseases have caused great catastrophes in human history, as in the example of the plague, which wiped out half of the population in Europe in the 14th century. Ebola virus and H7N9 avian influenza virus are 2 lethal pathogens that we have encountered in the second decade of the 21st century. Ebola infection is currently being seen in West Africa, and H7N9 avian flu appears to have settled in Southeast Asia. This article focuses on the current situation and the future prospects of these potential infectious threats to mankind.

An Ecological Framework of the Human Virome Provides Classification of Current Knowledge and Identifies Areas of Forthcoming Discovery

Recent advances in sequencing technologies have opened the door for the classification of the human virome. While taxonomic classification can be applied to the viruses identified in such studies, this gives no information as to the type of interaction the virus has with the host. As follow-up studies are performed to address these questions, the description of these virus-host interactions would be greatly enriched by applying a standard set of definitions that typify them. This paper describes a framework with which all members of the human virome can be classified based on principles of ecology. The scaffold not only enables categorization of the human virome, but can also inform research aimed at identifying novel virus-host interactions.

The pregnant healthcare worker: fact and fiction

PURPOSE OF REVIEW

A pregnant healthcare worker (HCW) may be at risk of occupational exposure to pathogens associated with increased maternal morbidity and mortality as well as perinatal complications. In this article, we review recent literature on infectious diseases commonly encountered in the healthcare setting and of highest concern for a pregnant HCW, focusing on prevention and management of exposures.

RECENT FINDINGS

Pregnancy does not seem to be an independent risk factor for occupationally acquired infectious diseases. Vaccination and standard precautions continue to be the most effective means of preventing transmission to HCWs. Pandemic 2009 influenza A (H1N1) is associated with increased risk of fetal death, highlighting the importance of influenza vaccination. A recent meta-analysis highlights the safety of influenza vaccination during pregnancy. New treatments for hepatitis C have not been studied in pregnancy but pose an important area for research and advancement. Cytomegalovirus immunoglobulin may play a role in postexposure prophylaxis but recent results are inconclusive.

SUMMARY

Primary prevention with vaccination and use of appropriate infection control precautions is imperative for prevention of occupationally acquired infectious diseases. Pregnant HCWs with occupational exposure to communicable diseases should be evaluated immediately for appropriate postexposure prophylaxis and followed for development of active infection.

Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination

Viruses with pandemic potential including H1N1, H5N1, and H5N7 influenza viruses, and severe acute respiratory syndrome (SARS)/Middle East respiratory syndrome (MERS) coronaviruses (CoV) have emerged in recent years. SARS-CoV, MERS-CoV, and influenza virus can survive on surfaces for extended periods, sometimes up to months. Factors influencing the survival of these viruses on surfaces include: strain variation, titre, surface type, suspending medium, mode of deposition, temperature and relative humidity, and the method used to determine the viability of the virus. Environmental sampling has identified contamination in field-settings with SARS-CoV and influenza virus, although the frequent use of molecular detection methods may not necessarily represent the presence of viable virus. The importance of indirect contact transmission (involving contamination of inanimate surfaces) is uncertain compared with other transmission routes, principally direct contact transmission (independent of surface contamination), droplet, and airborne routes. However, influenza virus and SARS-CoV may be shed into the environment and be transferred from environmental surfaces to hands of patients and healthcare providers. Emerging data suggest that MERS-CoV also shares these properties. Once contaminated from the environment, hands can then initiate self-inoculation of mucous membranes of the nose, eyes or mouth. Mathematical and animal models, and intervention studies suggest that contact transmission is the most important route in some scenarios. Infection prevention and control implications include the need for hand hygiene and personal protective equipment to minimize self-contamination and to protect against inoculation of mucosal surfaces and the respiratory tract, and enhanced surface cleaning and disinfection in healthcare settings.

Characterization of Viral Load, Viability and Persistence of Influenza A Virus in Air and on Surfaces of Swine Production Facilities

Indirect transmission of influenza A virus (IAV) in swine is poorly understood and information is lacking on levels of environmental exposure encountered by swine and people during outbreaks of IAV in swine barns. We characterized viral load, viability and persistence of IAV in air and on surfaces during outbreaks in swine barns. IAV was detected in pigs, air and surfaces from five confirmed outbreaks with 48% (47/98) of oral fluid, 38% (32/84) of pen railing and 43% (35/82) of indoor air samples testing positive by IAV RT-PCR. IAV was isolated from air and oral fluids yielding a mixture of subtypes (H1N1, H1N2 and H3N2). Detection of IAV RNA from air was sustained during the outbreaks with maximum levels estimated between 7 and 11 days from reported onset. Our results indicate that during outbreaks of IAV in swine, aerosols and surfaces in barns contain significant levels of IAV potentially representing an exposure hazard to both swine and people.

Influenza A virus transmission via respiratory aerosols or droplets as it relates to pandemic potential

Many respiratory viruses of humans originate from animals. For instance, there are now eight paramyxoviruses, four coronaviruses and four orthomxoviruses that cause recurrent epidemics in humans but were once confined to other hosts. In the last decade, several members of the same virus families have jumped the species barrier from animals to humans. Fortunately, these viruses have not become established in humans, because they lacked the ability of sustained transmission between humans. However, these outbreaks highlighted the lack of understanding of what makes a virus transmissible. In part triggered by the relatively high frequency of occurrence of influenza A virus zoonoses and pandemics, the influenza research community has started to investigate the viral genetic and biological traits that drive virus transmission via aerosols or respiratory droplets between mammals. Here we summarize recent discoveries on the genetic and phenotypic traits required for airborne transmission of zoonotic influenza viruses of subtypes H5, H7 and H9 and pandemic viruses of subtypes H1, H2 and H3. Increased understanding of the determinants and mechanisms of respiratory virus transmission is not only key from a basic scientific perspective, but may also aid in assessing the risks posed by zoonotic viruses to human health, and preparedness for such risks.

Replication and Transmission of the Novel Bovine Influenza D Virus in a Guinea Pig Model

Influenza D virus (FLUDV) is a novel influenza virus that infects cattle and swine. The goal of this study was to investigate the replication and transmission of bovine FLUDV in guinea pigs. Following direct intranasal inoculation of animals, the virus was detected in nasal washes of infected animals during the first 7 days postinfection. High viral titers were obtained from nasal turbinates and lung tissues of directly inoculated animals. Further, bovine FLUDV was able to transmit from the infected guinea pigs to sentinel animals by means of contact and not by aerosol dissemination under the experimental conditions tested in this study. Despite exhibiting no clinical signs, infected guinea pigs developed seroconversion and the viral antigen was detected in lungs of animals by immunohistochemistry. The observation that bovine FLUDV replicated in the respiratory tract of guinea pigs was similar to observations described previously in studies of gnotobiotic calves and pigs experimentally infected with bovine FLUDV but different from those described previously in experimental infections in ferrets and swine with a swine FLUDV, which supported virus replication only in the upper respiratory tract and not in the lower respiratory tract, including lung. Our study established that guinea pigs could be used as an animal model for studying this newly emerging influenza virus.

IMPORTANCE

Influenza D virus (FLUDV) is a novel emerging pathogen with bovine as its primary host. The epidemiology and pathogenicity of the virus are not yet known. FLUDV also spreads to swine, and the presence of FLUDV-specific antibodies in humans could indicate that there is a potential for zoonosis. Our results showed that bovine FLUDV replicated in the nasal turbinate and lungs of guinea pigs at high titers and was also able to transmit from an infected animal to sentinel animals by contact. The fact that bovine FLUDV replicated productively in both the upper and lower respiratory tracts of guinea pigs, similarly to virus infection in its native host, demonstrates that guinea pigs would be a suitable model host to study the replication and transmission potential of bovine FLUDV.

Concentration, Size Distribution, and Infectivity of Airborne Particles Carrying Swine Viruses

When pathogens become airborne, they travel associated with particles of different size and composition. Particle size determines the distance across which pathogens can be transported, as well as the site of deposition and the survivability of the pathogen. Despite the importance of this information, the size distribution of particles bearing viruses emitted by infectious animals remains unknown. In this study we characterized the concentration and size distribution of inhalable particles that transport influenza A virus (IAV), porcine reproductive and respiratory syndrome virus (PRRSV), and porcine epidemic diarrhea virus (PEDV) generated by acutely infected pigs and assessed virus viability for each particle size range. Aerosols from experimentally infected pigs were sampled for 24 days using an Andersen cascade impactor able to separate particles by size (ranging from 0.4 to 10 micrometer (μm) in diameter). Air samples collected for the first 9, 20 and the last 3 days of the study were analyzed for IAV, PRRSV and PEDV, respectively, using quantitative reverse transcription polymerase chain reaction (RT-PCR) and quantified as geometric mean copies/m³ within each size range. IAV was detected in all particle size ranges in quantities ranging from 5.5x10² (in particles ranging from 1.1 to 2.1μm) to 4.3x10⁵ RNA copies/m³ in the largest particles (9.0–10.0μm). PRRSV was detected in all size ranges except particles between 0.7 and 2.1μm in quantities ranging from 6x10² (0.4–0.7μm) to 5.1x10⁴ RNA copies/m³ (9.0–10.0μm). PEDV, an enteric virus, was detected in all particle sizes and in higher quantities than IAV and PRRSV (p < 0.0001) ranging from 1.3x10⁶ (0.4–0.7μm) to 3.5x10⁸ RNA copies/m³ (9.0–10.0μm). Infectious status was demonstrated for the 3 viruses, and in the case of IAV and PRRSV, viruses were isolated from particles larger than 2.1μm. In summary, our results indicated that airborne PEDV, IAV and PRRSV can be found in a wide range of particle sizes. However, virus viability is particle size dependent.

Aerosol-Transmitted Infections-a New Consideration for Public Health and Infection Control Teams

Since the emergence of the 2003 severe acute respiratory syndrome (SARS), the 2003 reemergence of avian A/H5N1, the emergence of the 2009 pandemic influenza A/H1N1, the 2012 emergence of Middle East respiratory syndrome (MERS), the 2013 emergence of avian A/H7N9 and the 2014 Ebola virus outbreaks, the potential for the aerosol transmission of infectious agents is now routinely considered in the investigation of any outbreak. Although many organisms have traditionally been considered to be transmitted by only one route (e.g. direct/indirect contact and/or faecal-orally), it is now apparent that the aerosol transmission route is also possible and opportunistic, depending on any potentially aerosol-generating procedures, the severity of illness and the degree and duration of pathogen-shedding in the infected patient, as well as the environment in which these activities are conducted.This article reviews the evidence and characteristics of some of the accepted (tuberculosis, measles, chickenpox, whooping cough) and some of the more opportunistic (influenza, Clostridium difficile, norovirus) aerosol-transmitted infectious agents and outlines methods of detecting and quantifying transmission.

Animal models for influenza virus transmission studies: a historical perspective

Animal models are used to simulate, under experimental conditions, the complex interactions among host, virus, and environment that affect the person-to-person spread of influenza viruses. The three species that have been most frequently employed, both past and present, as influenza virus transmission models-ferrets, mice, and guinea pigs-have each provided unique insights into the factors governing the efficiency with which these viruses pass from an infected host to a susceptible one. This review will highlight a few of these noteworthy discoveries, with a particular focus on the historical contexts in which each model was developed and the advantages and disadvantages of each species with regard to the study of influenza virus transmission among mammals.

Ionizing air affects influenza virus infectivity and prevents airborne-transmission

By the use of a modified ionizer device we describe effective prevention of airborne transmitted influenza A (strain Panama 99) virus infection between animals and inactivation of virus (>97%). Active ionizer prevented 100% (4/4) of guinea pigs from infection. Moreover, the device effectively captured airborne transmitted calicivirus, rotavirus and influenza virus, with recovery rates up to 21% after 40 min in a 19 m³ room. The ionizer generates negative ions, rendering airborne particles/aerosol droplets negatively charged and electrostatically attracts them to a positively charged collector plate. Trapped viruses are then identified by reverse transcription quantitative real-time PCR. The device enables unique possibilities for rapid and simple removal of virus from air and offers possibilities to simultaneously identify and prevent airborne transmission of viruses.

Influenza A Virus Coinfection through Transmission Can Support High Levels of Reassortment

The reassortment of gene segments between influenza viruses increases genomic diversity and plays an important role in viral evolution. We have shown previously that this process is highly efficient within a coinfected cell and, given synchronous coinfection at moderate or high doses, can give rise to ~60 to 70% of progeny shed from an animal host. Conversely, reassortment in vivo can be rendered undetectable by lowering viral doses or extending the time between infections. One might also predict that seeding of transmitted viruses into different sites within the target tissue could limit subsequent reassortment. Given the potential for stochastic factors to restrict reassortment during natural infection, we sought to determine its efficiency in a host coinfected through transmission. Two scenarios were tested in a guinea pig model, using influenza A/Panama/2007/99 (H3N2) virus (wt) and a silently mutated variant (var) thereof as parental virus strains. In the first, coinfection was achieved by exposing a naive guinea pig to two cagemates, one infected with wt and the other with var virus. When such exposure led to coinfection, robust reassortment was typically seen, with 50 to 100% of isolates carrying reassortant genomes at one or more time points. In the second scenario, naive guinea pigs were exposed to a cagemate that had been coinoculated with wt and var viruses. Here, reassortment occurred in the coinoculated donor host, multiple variants were transmitted, and reassortants were prevalent in the recipient host. Together, these results demonstrate the immense potential for reassortment to generate viral diversity in nature.

IMPORTANCE

Influenza viruses evolve rapidly under selection due to the generation of viral diversity through two mechanisms. The first is the introduction of random errors into the genome by the viral polymerase, which occurs with a frequency of approximately 10(-5) errors/nucleotide replicated. The second is reassortment, or the exchange of gene segments between viruses. Reassortment is known to occur readily under well-controlled laboratory conditions, but its frequency in nature is not clear. Here, we tested the hypothesis that reassortment efficiency following coinfection through transmission would be reduced compared to that seen with coinoculation. Contrary to this hypothesis, our results indicate that coinfection achieved through transmission supports high levels of reassortment. These results suggest that reassortment is not exquisitely sensitive to stochastic effects associated with transmission and likely occurs in nature whenever a host is infected productively with more than one influenza A virus.

Environmental Conditions Affect Exhalation of H3N2 Seasonal and Variant Influenza Viruses and Respiratory Droplet Transmission in Ferrets

The seasonality of influenza virus infections in temperate climates and the role of environmental conditions like temperature and humidity in the transmission of influenza virus through the air are not well understood. Using ferrets housed at four different environmental conditions, we evaluated the respiratory droplet transmission of two influenza viruses (a seasonal H3N2 virus and an H3N2 variant virus, the etiologic virus of a swine to human summertime infection) and concurrently characterized the aerosol shedding profiles of infected animals. Comparisons were made among the different temperature and humidity conditions and between the two viruses to determine if the H3N2 variant virus exhibited enhanced capabilities that may have contributed to the infections occurring in the summer. We report here that although increased levels of H3N2 variant virus were found in ferret nasal wash and exhaled aerosol samples compared to the seasonal H3N2 virus, enhanced respiratory droplet transmission was not observed under any of the environmental settings. However, overall environmental conditions were shown to modulate the frequency of influenza virus transmission through the air. Transmission occurred most frequently at 23°C/30%RH, while the levels of infectious virus in aerosols exhaled by infected ferrets agree with these results. Improving our understanding of how environmental conditions affect influenza virus infectivity and transmission may reveal ways to better protect the public against influenza virus infections.

Transmission in the guinea pig model

The ability of an influenza virus to transmit efficiently from human-to-human is a major factor in determining the epidemiological impact of that strain. The use of a relevant animal model to identify viral determinants of transmission, as well as host and environmental factors affecting transmission efficiency, is therefore critical for public health. The characterization of newly emerging influenza viruses in terms of their potential to transmit in a mammalian host is furthermore an important part of pandemic risk assessment. For these reasons, a guinea pig model of influenza virus transmission was developed in 2006. The guinea pig provides an important alternative to preexisting models for influenza. Most influenza viruses do not readily transmit among mice. Ferrets, while highly relevant, are expensive and can be difficult to obtain in high numbers. Moreover, it is generally accepted that efforts to accurately model human disease are strengthened by the use of multiple animal species. Herein, we provide an overview of influenza virus infectivity, growth, and transmission in the guinea pig and highlight knowledge gained on the topic of influenza virus transmission using the guinea pig model.

Seasonal and Pandemic Influenza Surveillance and Disease Severity

Continuous investments in influenza research, surveillance, and prevention efforts are critical to mitigate the consequences of annual influenza epidemics and pandemics. New influenza viruses emerge due to antigenic drift and antigenic shift evading human immune system and causing annual epidemics and pandemics. Three pandemics with varying disease severity occurred in the last 100 years. The disease burden and determinants of influenza severity depend on circulating viral strains and individual demographic and clinical factors. Surveillance is the most effective strategy for appropriate public health response. Active and passive surveillance methods are utilized to monitor influenza epidemics and emergence of novel viruses. Meaningful use of electronic health records could be a cost-effective approach to improved influenza surveillance

D701N mutation in the PB2 protein contributes to the pathogenicity of H5N1 avian influenza viruses but not transmissibility in guinea pigs

H5N1 highly pathogenic avian influenza virus (HPAIV) of clade 2.3.2 has been circulating in waterfowl in Southern China since 2003. Our previous studies showed that certain H5N1 HPAIV isolates within clade 2.3.2 from Southern China had high pathogenicity in different birds. Guinea pigs have been successfully used as models to evaluate the transmissibility of AIVs and other species of influenza viruses in mammalian hosts. However, few studies have reported pathogenicity and transmissibility of H5N1 HPAIVs of this clade in guinea pigs. In this study, we selected an H5N1 HPAIV isolate, A/duck/Guangdong/357/2008, to investigate the pathogenicity and transmissibility of the virus in guinea pigs. The virus had high pathogenicity in mice; additionally, it only replicated in some tissues of the guinea pigs without production of clinical signs, but was transmissible among guinea pigs. Interestingly, virus isolates from co-caged guinea pigs had the D701N mutation in the PB2 protein. These mutant viruses showed higher pathogenicity in mice and higher replication capability in guinea pigs but did not demonstrate enhanced the transmissibility among guinea pigs. These findings indicate the transmission of the H5N1 virus between mammals could induce virus mutations, and the mutant viruses might have higher pathogenicity in mammals without higher transmissibility. Therefore, the continued evaluation of the pathogenicity and transmissibility of avian influenza virus (AIVs) in mammals is critical to the understanding of the evolutionary characteristics of AIVs and the emergence of potential pandemic strains.

Environmental role in influenza virus outbreaks

The environmental drivers of influenza outbreaks are largely unknown. Despite more than 50 years of research, there are conflicting lines of evidence on the role of the environment in influenza A virus (IAV) survival, stability, and transmissibility. With the increasing and looming threat of pandemic influenza, it is important to understand these factors for early intervention and long-term control strategies. The factors that dictate the severity and spread of influenza would include the virus, natural and acquired hosts, virus-host interactions, environmental persistence, virus stability and transmissibility, and anthropogenic interventions. Virus persistence in different environments is subject to minor variations in temperature, humidity, pH, salinity, air pollution, and solar radiations. Seasonality of influenza is largely dictated by temperature and humidity, with cool-dry conditions enhancing IAV survival and transmissibility in temperate climates in high latitudes, whereas humid-rainy conditions favor outbreaks in low latitudes, as seen in tropical and subtropical zones. In mid-latitudes, semiannual outbreaks result from alternating cool-dry and humid-rainy conditions. The mechanism of virus survival in the cool-dry or humid-rainy conditions is largely determined by the presence of salts and proteins in the respiratory droplets. Social determinants of heath, including health equity, vaccine acceptance, and age-related illness, may play a role in influenza occurrence and spread.

Animal models for influenza viruses: implications for universal vaccine development

Influenza virus infections are a significant cause of morbidity and mortality in the human population. Depending on the virulence of the influenza virus strain, as well as the immunological status of the infected individual, the severity of the respiratory disease may range from sub-clinical or mild symptoms to severe pneumonia that can sometimes lead to death. Vaccines remain the primary public health measure in reducing the influenza burden. Though the first influenza vaccine preparation was licensed more than 60 years ago, current research efforts seek to develop novel vaccination strategies with improved immunogenicity, effectiveness, and breadth of protection. Animal models of influenza have been essential in facilitating studies aimed at understanding viral factors that affect pathogenesis and contribute to disease or transmission. Among others, mice, ferrets, pigs, and nonhuman primates have been used to study influenza virus infection in vivo, as well as to do pre-clinical testing of novel vaccine approaches. Here we discuss and compare the unique advantages and limitations of each model.

Humidity and respiratory virus transmission in tropical and temperate settings

Influenza and respiratory syncytial virus (RSV) are similarly structured viruses with similar environmental survival, but different routes of transmission. While RSV is transmitted predominantly by direct and indirect contact, influenza is also transmitted by aerosol. The cold, dry conditions of temperate winters appear to encourage the transmission of both viruses, by increasing influenza virus survival in aerosols, and increasing influenza and RSV survival on surfaces. In contrast, the hot, wet conditions of tropical rainy seasons appear to discourage aerosol transmission of influenza, by reducing the amount of influenza virus that is aerosolized, and probably also by reducing influenza survival in aerosol. The wet conditions of tropical rainy seasons may, however, encourage contact transmission of both viruses, by increasing the amount of virus that is deposited on surfaces, and by increasing virus survival in droplets on surfaces. This evidence suggests that the increased incidence of influenza and RSV in tropical rainy seasons may be due to increased contact transmission. This hypothesis is consistent with the observation that tropical rainy seasons appear to encourage the transmission of RSV more than influenza. More research is required to examine the environmental survival of respiratory viruses in the high humidity and temperature of the tropics.

Quantifying the risk of respiratory infection in healthcare workers performing high-risk procedures

This study determined the risk of respiratory infection associated with high-risk procedures (HRPs) performed by healthcare workers (HCWs) in high-risk settings. We prospectively studied 481 hospital HCWs in China, documented risk factors for infection, including performing HRPs, measured new infections, and analysed whether HRPs predicted infection. Infection outcomes were clinical respiratory infection (CRI), laboratory-confirmed viral or bacterial infection, and an influenza infection. About 12% (56/481) of the study participants performed at least one HRP, the most common being airway suctioning (7·7%, 37/481). HCWs who performed a HRP were at significantly higher risk of developing CRI and laboratory-confirmed infection [adjusted relative risk 2·9, 95% confidence interval (CI) 1·42-5·87 and 2·9, 95% CI 1·37-6·22, respectively]. Performing a HRP resulted in a threefold increase in the risk of respiratory infections. This is the first time the risk has been prospectively quantified in HCWs, providing data to inform occupational health and safety policies.

Effects of surface material, ventilation, and human behavior on indirect contact transmission risk of respiratory infection

Infectious particles can be deposited on surfaces. Susceptible persons who contacted these contaminated surfaces may transfer the pathogens to their mucous membranes via hands, leading to a risk of respiratory infection. The exposure and infection risk contributed by this transmission route depend on indoor surface material, ventilation, and human behavior. In this study, quantitative infection risk assessments were used to compare the significances of these factors. The risks of three pathogens, influenza A virus, respiratory syncytial virus (RSV), and rhinovirus, in an aircraft cabin and in a hospital ward were assessed. Results showed that reducing the contact rate is relatively more effective than increasing the ventilation rate to lower the infection risk. Nonfabric surface materials were found to be much more favorable in the indirect contact transmission for RSV and rhinovirus than fabric surface materials. In the cases considered in this study, halving the ventilation rate and doubling the hand contact rate to surfaces and the hand contact rate to mucous membranes would increase the risk by 3.7-16.2%, 34.4-94.2%, and 24.1-117.7%, respectively. Contacting contaminated nonfabric surfaces may pose an indirect contact risk up to three orders of magnitude higher than that of contacting contaminated fabric surfaces. These findings provide more consideration for infection control and building environmental design.

Routes of influenza transmission

Remarkably little is known definitively about the modes of influenza transmission. Thus, important health policy and infection control issues remain unresolved. These shortcomings have been exposed in national and international pandemic preparedness activities over recent years. Indeed, WHO, CDC, ECDC and the U.S. Institute of Medicine have prioritised understanding the modes of influenza transmission as a critical need for pandemic planning. Studying influenza transmission is difficult; seasonality, unpredictable attack rates, role of environmental parameters such as temperature and humidity, numbers of participants required and confounding variables all present considerable obstacles to the execution of definitive studies. A range of investigations performed to date have failed to provide definitive answers and key questions remain. Reasons for this include the fact that many studies have not sought to investigate routes of transmission as a primary objective (instead, they have evaluated specific interventions) and that fieldwork in natural settings, specifically assessing the dynamics and determinants of transmission between humans, has been limited. The available evidence suggests that all routes of transmission (droplet, aerosol and contact) have a role to play; their relative significance will depend on the set of circumstances acting at a given time. Dictating the process are factors related to the virus itself, the host and the environment.

Healthcare providers as sources of vaccine-preventable diseases

Vaccine-preventable infectious diseases may be introduced into the healthcare setting and pose a serious risk to vulnerable populations including immunocompromised patients. Healthcare providers (HCPs) are exposed to these pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. The primary method of protection from work-related infection risk is vaccination that protects not only an individual HCP from disease, but also subsequent patients in contact with that HCP. Individual HCPs and healthcare institutions must balance the ethical and professional responsibility to protect their patients from nosocomial transmission of preventable infections with HCP autonomy. This article reviews known cases of HCP-to-patient transmission of the most common vaccine-preventable infections encountered in the healthcare setting including hepatitis B virus, influenza virus, Bordetella pertussis, varicella-zoster virus, measles, mumps and rubella virus. The impact of HCP vaccination on patient care and current recommendations for HCP vaccination against vaccine-preventable infectious diseases are also reviewed.

Animal models for influenza virus pathogenesis, transmission, and immunology

In humans, infection with an influenza A or B virus manifests typically as an acute and self-limited upper respiratory tract illness characterized by fever, cough, sore throat, and malaise. However, influenza can present along a broad spectrum of disease, ranging from sub-clinical or even asymptomatic infection to a severe primary viral pneumonia requiring advanced medical supportive care. Disease severity depends upon the virulence of the influenza virus strain and the immune competence and previous influenza exposures of the patient. Animal models are used in influenza research not only to elucidate the viral and host factors that affect influenza disease outcomes in and spread among susceptible hosts, but also to evaluate interventions designed to prevent or reduce influenza morbidity and mortality in man. This review will focus on the three animal models currently used most frequently in influenza virus research - mice, ferrets, and guinea pigs - and discuss the advantages and disadvantages of each.

How should social mixing be measured: comparing web-based survey and sensor-based methods

Background

Contact surveys and diaries have conventionally been used to measure contact networks in different settings for elucidating infectious disease transmission dynamics of respiratory infections. More recently, technological advances have permitted the use of wireless sensor devices, which can be worn by individuals interacting in a particular social context to record high resolution mixing patterns. To date, a direct comparison of these two different methods for collecting contact data has not been performed.

Methods

We studied the contact network at a United States high school in the spring of 2012. All school members (i.e., students, teachers, and other staff) were invited to wear wireless sensor devices for a single school day, and asked to remember and report the name and duration of all of their close proximity conversational contacts for that day in an online contact survey. We compared the two methods in terms of the resulting network densities, nodal degrees, and degree distributions. We also assessed the correspondence between the methods at the dyadic and individual levels.

Results

We found limited congruence in recorded contact data between the online contact survey and wireless sensors. In particular, there was only negligible correlation between the two methods for nodal degree, and the degree distribution differed substantially between both methods. We found that survey underreporting was a significant source of the difference between the two methods, and that this difference could be improved by excluding individuals who reported only a few contact partners. Additionally, survey reporting was more accurate for contacts of longer duration, and very inaccurate for contacts of shorter duration. Finally, female participants tended to report more accurately than male participants.

Conclusions

Online contact surveys and wireless sensor devices collected incongruent network data from an identical setting. This finding suggests that these two methods cannot be used interchangeably for informing models of infectious disease dynamics.

Novel H7N9 influenza virus shows low infectious dose, high growth rate, and efficient contact transmission in the guinea pig model

The zoonotic outbreak of H7N9 subtype avian influenza virus that occurred in eastern China in the spring of 2013 resulted in 135 confirmed human cases, 44 of which were lethal. Sequencing of the viral genome revealed a number of molecular signatures associated with virulence or transmission in mammals. We report here that, in the guinea pig model, a human isolate of novel H7N9 influenza virus, A/Anhui/1/2013 (An/13), is highly dissimilar to an H7N1 avian isolate and instead behaves similarly to a human seasonal strain in several respects. An/13 was found to have a low 50% infectious dose, grow to high titers in the upper respiratory tract, and transmit efficiently among cocaged guinea pigs. The pH of fusion of the hemagglutinin (HA) and the binding of virus to fixed guinea pig tissues were also examined. The An/13 HA displayed a relatively elevated pH of fusion characteristic of many avian strains, and An/13 resembled avian viruses in terms of attachment to tissues. One important difference was seen between An/13 and both the H3N2 human and the H7N1 avian viruses: when inoculated intranasally at a high dose, only the An/13 virus led to productive infection of the lower respiratory tract of guinea pigs. In sum, An/13 was found to retain fusion and attachment properties of an avian influenza virus but displayed robust growth and contact transmission in the guinea pig model atypical of avian strains and indicative of mammalian adaptation.

Mode of parainfluenza virus transmission determines the dynamics of primary infection and protection from reinfection

Little is known about how the mode of respiratory virus transmission determines the dynamics of primary infection and protection from reinfection. Using non-invasive imaging of murine parainfluenza virus 1 (Sendai virus) in living mice, we determined the frequency, timing, dynamics, and virulence of primary infection after contact and airborne transmission, as well as the tropism and magnitude of reinfection after subsequent challenge. Contact transmission of Sendai virus was 100% efficient, phenotypically uniform, initiated and grew to robust levels in the upper respiratory tract (URT), later spread to the lungs, grew to a lower level in the lungs than the URT, and protected from reinfection completely in the URT yet only partially in the lungs. Airborne transmission through 7.6-cm and 15.2-cm separations between donor and recipient mice was 86%-100% efficient. The dynamics of primary infection after airborne transmission varied between individual mice and included the following categories: (a) non-productive transmission, (b) tracheal dominant, (c) tracheal initiated yet respiratory disseminated, and (d) nasopharyngeal initiated yet respiratory disseminated. Any previous exposure to Sendai virus infection protected from mortality and severe morbidity after lethal challenge. Furthermore, a higher level of primary infection in a given respiratory tissue (nasopharynx, trachea, or lungs) was inversely correlated with the level of reinfection in that same tissue. Overall, the mode of transmission determined the dynamics and tropism of primary infection, which in turn governed the level of seroconversion and protection from reinfection. These data are the first description of the dynamics of respiratory virus infection and protection from reinfection throughout the respiratory tracts of living animals after airborne transmission. This work provides a basis for understanding parainfluenza virus transmission and protective immunity and for developing novel vaccines and non-pharmaceutical interventions.

The experimental aerosol transmission of influenza virus

The threat of a virulent, highly transmissible pandemic virus has motivated an escalating research effort to identify the transmissible genotypes of animal viruses that cross over into the human population (animal–human transmission) and sustain human–human transmission. In addition to the pursuit of the viral genotype, a greater understanding of the host-virus phenotype of infectiousness, transmissibility and susceptibility will be required. This review examines experimental animal transmission of influenza for insights into human influenza transmission. Transmission is viewed as sequential steps that the virus must pass critical thresholds to achieve transmission and ultimately survival in the human host. In particular, a quantitative understanding in animal models of viral replication efficiency, airway viral load, exhaled viral aerosol load, environmental virus survival and host susceptibility will likely yield important insights. Computational modeling will enhance animal model data, as well as guide the use of pandemic mitigation strategies.

Survival of influenza virus on human fingers

Indirect transmission of the influenza virus via finger contamination with respiratory mucus droplets has been hypothesized to contribute to transmission in the community. Under laboratory conditions, influenza-infected respiratory droplets were reconstituted as close as possible to natural conditions. We investigated experimentally the survival of influenza A (H3N2) and A (H1N1)pdm09 viruses on human fingers. Infectious virus was easily recoverable on all fingers 1 min after fingertip contamination but then decreased very rapidly. After 30 min, infectious virus was detectable in only a small minority of subjects. Infectious viruses were detected for a longer period of time when droplets of larger size containing a higher number of particles were tested or when the viral concentration increased. A rapid decrease in infectiousness was observed when droplet integrity was disrupted. Our findings could help to set up the promotion of hand hygiene to prevent influenza hand contamination.

Airborne detection and quantification of swine influenza a virus in air samples collected inside, outside and downwind from swine barns

Airborne transmission of influenza A virus (IAV) in swine is speculated to be an important route of virus dissemination, but data are scarce. This study attempted to detect and quantify airborne IAV by virus isolation and RRT-PCR in air samples collected under field conditions. This was accomplished by collecting air samples from four acutely infected pig farms and locating air samplers inside the barns, at the external exhaust fans and downwind from the farms at distances up to 2.1 km. IAV was detected in air samples collected in 3 out of 4 farms included in the study. Isolation of IAV was possible from air samples collected inside the barn at two of the farms and in one farm from the exhausted air. Between 13% and 100% of samples collected inside the barns tested RRT-PCR positive with an average viral load of 3.20E+05 IAV RNA copies/m³ of air. Percentage of exhaust positive air samples also ranged between 13% and 100% with an average viral load of 1.79E+04 RNA copies/m³ of air. Influenza virus RNA was detected in air samples collected between 1.5 and 2.1 Km away from the farms with viral levels significantly lower at 4.65E+03 RNA copies/m³. H1N1, H1N2 and H3N2 subtypes were detected in the air samples and the hemagglutinin gene sequences identified in the swine samples matched those in aerosols providing evidence that the viruses detected in the aerosols originated from the pigs in the farms under study. Overall our results indicate that pigs can be a source of IAV infectious aerosols and that these aerosols can be exhausted from pig barns and be transported downwind. The results from this study provide evidence of the risk of aerosol transmission in pigs under field conditions.

Regional similarities in seasonal mortality across the United States: an examination of 28 metropolitan statistical areas

Human mortality exhibits a strong seasonal pattern with deaths in winter far exceeding those in the summer. While the pattern itself is clear, there have been very few studies examining whether the magnitude or timing of seasonal mortality varies considerably across space. Thus, the goal of this study is to conduct a comprehensive geographic analysis of seasonal mortality across the United States and to uncover systematic regional differences in such mortality. Unique seasonal mortality curves were created for 28 metropolitan statistical areas across the United States, and the amplitude and timing of mortality peaks were determined. The findings here indicate that the seasonality of mortality exhibits strong spatial variation with the largest seasonal mortality amplitudes found in the southwestern United States and the smallest in the North, along with South Florida. In addition, there were strong intra-regional similarities that exist among the examined cities, implying that environmental factors are more important than social factors in determining seasonal mortality response. This work begins to fill a large gap within the scientific literature concerning the geographic variation and underlying causes of seasonal mortality across the United States.

Comparison of the levels of infectious virus in respirable aerosols exhaled by ferrets infected with influenza viruses exhibiting diverse transmissibility phenotypes

Influenza viruses pose a major public health burden to communities around the world by causing respiratory infections that can be highly contagious and spread rapidly through the population. Despite extensive research on influenza viruses, the modes of transmission occurring most often among humans are not entirely clear. Contributing to this knowledge gap is the lack of an understanding of the levels of infectious virus present in respirable aerosols exhaled from infected hosts. Here, we used the ferret model to evaluate aerosol shedding patterns and measure the amount of infectious virus present in exhaled respirable aerosols. By comparing these parameters among a panel of human and avian influenza viruses exhibiting diverse respiratory droplet transmission efficiencies, we are able to report that ferrets infected by highly transmissible influenza viruses exhale a greater number of aerosol particles and more infectious virus within respirable aerosols than ferrets infected by influenza viruses that do not readily transmit. Our findings improve our understanding of the ferret transmission model and provide support for the potential for influenza virus aerosol transmission.

Relationship between airborne detection of influenza A virus and the number of infected pigs

Influenza A virus infects a wide range of species including both birds and mammals (including humans). One of the key routes by which the virus can infect populations of animals is by aerosol transmission. This study explored the relationship between number of infected pigs and the probability of detecting influenza virus RNA in bioaerosols through the course of an acute infection. Bioaerosols were collected using a cyclonic collector in two groups of 7 week-old pigs that were experimentally infected by exposure with a contact infected pig (seeder pig). After contact exposure, individual pig nasal swab samples were collected daily and air samples were collected three times per day for 8 days. All samples were tested for influenza by real-time reverse transcriptase (RRT)-PCR targeting the influenza virus matrix gene. All pigs' nasal swabs became influenza virus RRT-PCR positive upon exposure to the infected seeder pig. Airborne influenza was detected in 28/43 (65%) air samples. The temporal dynamics of influenza virus detection in air samples was in close agreement with the nasal shedding pattern in the infected pigs. First detection of positive bioaerosols happened at 1 day post contact (DPC). Positive bioaerosols were consistently detected between 3 and 6 DPC, a time when most pigs were also shedding virus in nasal secretions. Overall, the odds of detecting a positive air sample increased 2.2 times for every additional nasal swab positive pig in the group. In summary, there was a strong relationship between the number of pigs shedding influenza virus in nasal secretions and the generation of bioaerosols during the course of an acute infection.

Which Health Care Workers Were Most Affected During the Spring 2009 H1N1 Pandemic?

Objectives: To identify health care workers most at risk for H1N1 infection before vaccination and compare health outcomes after vaccination.

Methods: The indices used to gauge employee health were laboratory-confirmed H1N1 data, laboratory-confirmed influenza A data, and employee sick hours records. In phase 1 of this 2-phase study, absenteeism records for 6,093 hospital employees before vaccine administration were analyzed according to department and employee position during the spring 2009 H1N1 pandemic.

Results: Records of 123 confirmed reports of laboratory-confirmed influenza A or novel H1N1 infections in hospital employees were also analyzed. Two thirds of the H1N1 cases occurred during June (infection rates in parentheses): 34 in physicians and medical personnel (6.7%), 36 in nurses and clinical technicians (2.2%), 39 in Administrative & Support Personnel (infection rate = 1.2%), 3 in Social Workers & Counselors (infection rate = 1.0%), 8 in Housekeeping & Food Services (infection rate = 2.7%), and 3 in Security & Transportation (infection rate=3.9%). When analyzed according to department, the adult emergency department (infection rate = 28.8%) and the pediatric emergency department (infection rate = 25.0%) had the highest infection rates per department.

Conclusions: Of the reported cases of H1N1 in health care workers, 49% occurred in a population that constitutes less than 20% of the total population studied. Physicians and medical personnel had a higher infection rate than other employee positions, whereas ED personnel had the highest infection rate.

(Disaster Med Public Health Preparedness. 2010;4:47-54)

Climate change and influenza: the likelihood of early and severe influenza seasons following warmer than average winters

The 2012-13 influenza season had an unusually early and severe start in the US, succeeding the record mild 2011-12 influenza season, which occurred during the fourth warmest winter on record. Our analysis of climate and past US influenza epidemic seasons between 1997-98 to present indicates that warm winters tend to be followed by severe epidemics with early onset, and that these patterns are seen for both influenza A and B. We posit that fewer people are infected with influenza during warm winters, thereby leaving an unnaturally large fraction of susceptible individuals in the population going into the next season, which can lead to early and severe epidemics. In the event of continued global warming, warm winters such as that of 2011-12 are expected to occur more frequently. Our results thus suggest that expedited manufacture and distribution of influenza vaccines after mild winters has the potential to mitigate the severity of future influenza epidemics.

Influence of extreme weather and meteorological anomalies on outbreaks of influenza A (H1N1)

Biological experiments and epidemiological evidence indicate that variations in environment have important effect on the occurrence and transmission of epidemic influenza. It is therefore important to understand the characteristic patterns of transmission for prevention of disease and reduction of disease burden. Based on case records, we analyzed the environmental characteristics including climate variables in Changsha, and then constructed a meteorological anomaly susceptive-infective-removal (SIR) model on the basis of the results of influenza A (H1N1) transmission. The results showed that the outbreak of influenza A (H1N1) in Changsha showed significant correlation with meteorological conditions; the spread of influenza was sensitive to meteorological anomalies, and that the outbreak of influenza A (H1N1) in Changsha was influenced by a combination of absolute humidity anomalous weather conditions, contact rates of the influenza patients and changes in population movements. These findings will provide helpful information regarding prevention strategies under different conditions, a fresh understanding of the emergence and re-emergence of influenza outbreaks, and a new perspective on the transmission dynamics of influenza.

Model analysis of fomite mediated influenza transmission

Fomites involved in influenza transmission are either hand- or droplet-contaminated. We evaluated the interactions of fomite characteristics and human behaviors affecting these routes using an Environmental Infection Transmission System (EITS) model by comparing the basic reproduction numbers (R₀) for different fomite mediated transmission pathways. Fomites classified as large versus small surface sizes (reflecting high versus low droplet contamination levels) and high versus low touching frequency have important differences. For example, 1) the highly touched large surface fomite (public tables) has the highest transmission potential and generally strongest control measure effects; 2) transmission from droplet-contaminated routes exceed those from hand-contaminated routes except for highly touched small surface fomites such as door knob handles; and 3) covering a cough using the upper arm or using tissues effectively removes virus from the system and thus decreases total fomite transmission. Because covering a cough by hands diverts pathogens from the droplet-fomite route to the hand-fomite route, this has the potential to increase total fomite transmission for highly touched small surface fomites. An improved understanding and more refined data related to fomite mediated transmission routes will help inform intervention strategies for influenza and other pathogens that are mediated through the environment.

Modeling rapidly disseminating infectious disease during mass gatherings

We discuss models for rapidly disseminating infectious diseases during mass gatherings (MGs), using influenza as a case study. Recent innovations in modeling and forecasting influenza transmission dynamics at local, regional, and global scales have made influenza a particularly attractive model scenario for MG. We discuss the behavioral, medical, and population factors for modeling MG disease transmission, review existing model formulations, and highlight key data and modeling gaps related to modeling MG disease transmission. We argue that the proposed improvements will help integrate infectious-disease models in MG health contingency plans in the near future, echoing modeling efforts that have helped shape influenza pandemic preparedness plans in recent years.