Avian influenza virus in pregnancy

Beyond COVID-19, the case for collecting, analysing and using sex-disaggregated data and gendered data to inform outbreak response: a scoping review

INTRODUCTION

Understanding sex and gender differences during outbreaks is critical to delivering an effective response. Although recommendations and minimum requirements exist, the incorporation of sex-disaggregated data and gender analysis into outbreak analytics and response for informed decision-making remains infrequent. A scoping review was conducted to provide an overview of the extent of sex-disaggregated data and gender analysis in outbreak response within low- and middle-income countries (LMICs).

METHODS

Five databases were searched for peer-reviewed literature examining sex- and gender-specific outcomes for communicable disease outbreaks published in English between 1 January 2012 and 12 April 2022. An adapted version of the WHO's Gender Analysis Matrix was used to synthesise evidence, which was then mapped across four phases of the outbreak timeline: prevention, detection, treatment/management and recovery.

RESULTS

71 articles met inclusion criteria and were included in this review. Sex-, gender-, and pregnancy-related disparities were identified throughout all four phases of the outbreak timeline. These disparities encompassed a wide range of risk factors for disease, vulnerability, access to and use of services, health-seeking behaviour, healthcare options, as well as experiences in healthcare settings and health and social outcomes and consequences.

CONCLUSION

Significant gender-evidence gaps remain in outbreak response. Evidence that is available illustrates that sex and gender disparities in outbreaks vary by disease, setting and population, and these differences play significant roles in shaping outbreak dynamics. As such, failing to collect, analyse or use sex-disaggregated data and gendered data during outbreaks results in less effective responses, differential adverse health outcomes, increased vulnerability among certain groups and insufficient evidence for effective prevention and response efforts. Systematic sex- and gender-based analyses to ensure gender-responsive outbreak prevention, detection, treatment/management and recovery are urgently needed.

Systematic Review of Avian Influenza Virus Infection and Outcomes during Pregnancy

Human cases of avian influenza A(H5N2) and A(H5N1) viruses associated with outbreaks in birds and mammals are increasing globally, raising concerns about the possibility of a future avian influenza pandemic. We conducted a systematic review examining 30 reported cases of avian influenza in pregnant women. We found high mortality rates for mothers (90.0%, 27/30) and their babies (86.7%, 26/30) when women were infected with avian influenza virus during pregnancy. Despite being a high-risk population and having worse health outcomes across multiple pandemics, pregnant women are often excluded from vaccine trials. However, as the risk for a new pandemic increases and human vaccines against avian influenza are developed, early inclusion of pregnant women in clinical trials can inform the risk-benefit analysis for both the mother and their newborn infant. Early inclusion of pregnant women in public health vaccination programs is vital for protecting this high-risk population.

Epidemiological characterization of human infection with H5N6 avian influenza

Background

In recent years, there have been frequent reports of human infection with H5N6 avian influenza. However, the fundamental characteristics of the disease remain unclear. This paper conducts a systematic review to explore the epidemiological features of the disease, aiming to provide a foundation for epidemic prevention and control and to serve as a reference for clinical diagnosis.

Method

A systematic search was performed in PubMed, Web of Science, CNKI, Wanfang and gray literature up to November 15, 2023. All articles were about the epidemic features of the H5N6 subtype of avian influenza, written in English or Chinese.

Results

This review encompasses 24 documented outbreaks of human H5N6 avian influenza, exclusively reported in southern China. The age range of cases spanned from under 2 years old to 81 years old. The incubation period ranged from 1 to 13 days, with a mean of 4.3 days. Among the 24 cases, 22 individuals had a documented history of contact with poultry. Of the 23 cases with available prognosis data, 12 resulted in fatalities, yielding a significant fatality rate of 52.2%. A noteworthy observation is that all cases with a history of contact with sick and dead poultry resulted in fatalities, and the difference in fatality rates between this group and others was statistically significant (χ2 = 7.441, p = 0.014). This study identified a total of 888 close contacts, none of whom demonstrated infection.

Conclusion

This study represents a comprehensive summary of the epidemiological characteristics of human H5N6 avian influenza. Significantly, it sheds light on the incubation period of the disease and underscores a potential elevated risk of mortality among patients with a history of contact with sick and dead poultry.

The regulated cell death at the maternal-fetal interface: beneficial or detrimental?

Regulated cell death (RCD) plays a fundamental role in placental development and tissue homeostasis. Placental development relies upon effective implantation and invasion of the maternal decidua by the trophoblast and an immune tolerant environment maintained by various cells at the maternal-fetal interface. Although cell death in the placenta can affect fetal development and even cause pregnancy-related diseases, accumulating evidence has revealed that several regulated cell death were found at the maternal-fetal interface under physiological or pathological conditions, the exact types of cell death and the precise molecular mechanisms remain elusive. In this review, we summarized the apoptosis, necroptosis and autophagy play both promoting and inhibiting roles in the differentiation, invasion of trophoblast, remodeling of the uterine spiral artery and decidualization, whereas ferroptosis and pyroptosis have adverse effects. RCD serves as a mode of communication between different cells to better maintain the maternal-fetal interface microenvironment. Maintaining the balance of RCD at the maternal-fetal interface is of utmost importance for the development of the placenta, establishment of an immune microenvironment, and prevention of pregnancy disorders. In addition, we also revealed an association between abnormal expression of key molecules in different types of RCD and pregnancy-related diseases, which may yield significant insights into the pathogenesis and treatment of pregnancy-related complications.

Influenza H7N9 virus disrupts the monolayer human brain microvascular endothelial cells barrier in vitro

Influenza H7N9 virus causes human infections with about 40% case fatality rate. The severe cases usually present with pneumonia; however, some present with central nervous system complications. Pneumonia syndrome is attributed to the cytokine storm after infection with H7N9, but the pathogenic mechanism of central nervous system complications has not been clarified. This study used immortalized human brain microvascular endothelial cells hCMEC/D3 to simulate the blood-brain barrier. It demonstrated that H7N9 virus could infect brain microvascular endothelial cells and compromise the blood-brain barrier integrity and permeability by down-regulating the expression of cell junction-related proteins, including claudin-5, occludin, and vascular endothelial (VE)-cadherin. These results suggested that H7N9 could infect the blood-brain barrier in vitro and affect its functions, which could be a potential mechanism for the pathogenesis of H7N9 viral encephalopathy.

The perinatal health challenges of emerging and re-emerging infectious diseases: A narrative review

The world has seen numerous infectious disease outbreaks in the past decade. In many cases these outbreaks have had considerable perinatal health consequences including increased risk of preterm delivery (e.g., influenza, measles, and COVID-19), and the delivery of low birth weight or small for gestational age babies (e.g., influenza, COVID-19). Furthermore, severe perinatal outcomes including perinatal and infant death are a known consequence of multiple infectious diseases (e.g., Ebola virus disease, Zika virus disease, pertussis, and measles). In addition to vaccination during pregnancy (where possible), pregnant women, are provided some level of protection from the adverse effects of infection through community-level application of evidence-based transmission-control methods. This review demonstrates that it takes almost 2 years for the perinatal impacts of an infectious disease outbreak to be reported. However, many infectious disease outbreaks between 2010 and 2020 have no associated pregnancy data reported in the scientific literature, or pregnancy data is reported in the form of case-studies only. This lack of systematic data collection and reporting has a negative impact on our understanding of these diseases and the implications they may have for pregnant women and their unborn infants. Monitoring perinatal health is an essential aspect of national and global healthcare strategies as perinatal life has a critical impact on early life mortality as well as possible effects on later life health. The unpredictable nature of emerging infections and the potential for adverse perinatal outcomes necessitate that we thoroughly assess pregnancy and perinatal health implications of disease outbreaks and their public health interventions in tandem with outbreak response efforts. Disease surveillance programs should incorporate perinatal health monitoring and health systems around the world should endeavor to continuously collect perinatal health data in order to quickly update pregnancy care protocols as needed.

Pregnancy-associated decrease of Siaα2-3Gal-linked glycans on salivary glycoproteins affects their binding ability to avian influenza virus

Salivary glycoproteins are known as an important barrier to inhibit influenza infection by presenting sialic acid (Sia) ligands that can bind with viral hemagglutination. Here, to further understand why pregnant women are more vulnerable to avian influenza virus (AIV), we investigated the alteration of protein sialylation in the saliva of women during pregnancy and postpartum, and its impact on the saliva binding affinity to AIV. Totally 1200 saliva samples were collected, the expression levels of terminal α2-3/6-linked Sia on salivary proteins were tested and validated, and the binding activities of salivary proteins were assessed against 3 strains of AIV and the H1N1 vaccine. Result showed that the expression of terminal α2-3-linked Sia in the saliva of women decreased dramatically during pregnancy compared to that of non-pregnancy control, especially for women in the second or third trimester (fold change = 0.53 and 0.37, p < 0.001). And their salivary protein binding ability to AIV declined accordingly. The variation of terminal α2-3-linked Sia on salivary MUC5B and IgA was consistent with the above results. This study indicates that the decrease of terminal α2-3-linked Sia on salivary glycoproteins of pregnant women affects their binding ability to AIV, which may provide new insights into AIV prevention and control.

Respiratory viral infections during pregnancy: effects of SARS-CoV-2 and other related viruses over the offspring

Little is known about the consequences of viral infection for pregnant woman or for the fetus. This issue became important with the appearance of the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). The infection with SARS-CoV-2 causes a respiratory syndrome known as COVID-19. The fast spreading around the world and the fact that without a treatment or vaccine humans are completely exposed, converts emerging viral diseases in a significant risk for pregnant women and their infants. At this time, during SARS-CoV-2 pandemics pregnant women are not considered as a risk population and little is known about the effects of viral infections over the offspring although the amount of emerging evidence showing detrimental effects for the mother and the fetus. This issue highlights the importance to understand the effects of viral infections during pregnancy. In this work, we analyze the effects of viral infections, like SARS-CoV-2 and other related viruses during pregnancy over the mother and the consequences for the offspring.

Pregnancy level of estradiol attenuated virus-specific humoral immune response in H5N1-infected female mice despite inducing anti-inflammatory protection

Estradiol, a major female steroid produced during pregnancy, has been reported to protect ovariectomized animals against H1N1 influenza infections via its anti-inflammatory effects. However, it remains unclear why pregnant women with high gestational estradiol levels are highly susceptible to influenza infections. This study was aimed to investigate the effects of pregnancy level of estradiol on female immunity against H5N1 infection in Balb/c mice. A sex-dependent susceptibility to H5N1 infection (higher morbidity and higher mortality) was observed in both pregnant and non-pregnant female mice as compared to male mice. Subcutaneous implantation of estradiol pellets increased serum estradiol concentrations of non-pregnant female mice to the pregnancy level. These mice were protected from H5N1 infection through downregulation of pulmonary pro-inflammatory cytokines. However, the production of virus-specific antibodies after infection was significantly delayed in estradiol-implanted mice when compared to placebos. Virus-specific IgG-secreting and IL-4-secreting cells were also reduced in estradiol-implanted mice. Similarly, lower antibody titers to seasonal vaccine antigens were found in pregnant women as compared to non-pregnant females without hormone usage. Our results indicate that estradiol levels equivalent to those found during pregnancy have divergent effects on female immunity against influenza, highlighting the importance of vaccination during pregnancy to prevent severe influenza infections.

Fatal avian influenza A(H5N1) infection in a 36-week pregnant woman survived by her newborn in Sóc Trăng Province, Vietnam, 2012

Background

Reports of pregnant women infected with avian influenza are rare. Studies showed that A/H5N1 virus can penetrate the placental barrier and infect the fetus. Of six documented cases, four died and two survivors had a spontaneous abortion.

Objectives

We report a clinical, outcome and epidemiological characteristics of a 36‐week pregnant woman infected with A/H5N1 and her newborn in Soc Trang province of Vietnam in 2012.

Methods

Epidemiological and laboratory investigations were conducted. Clinical manifestations, progress, treatment and outcome of the case‐patient and her newborn were collected. Human tracheal aspirate, throat swab and serum specimens were tested for influenza A/H5N1, A/H3N1, A/H1N1pdm09 and B by real‐time RT‐PCR and genome sequencing. Poultry throat and rectal swabs were tested by PCR and virus isolation.

Results

Case‐patient hospitalized with high fever and cough, and died after onset 6 days. She continuously slaughtered sick poultry 5 days before illness onset. Clinical manifestation showed rapid progressive severe pneumonia. Her tracheal aspirate sample was positive influenza A/H5N1 virus. Her new‐born was delivered by caesarean section with low birth weight and early onset pneumonia, however fully recovered after 16 days treatment. Neonate's throat swabs and paired serum samples tested negative for influenza A/H5N1. Clade 1.1 A/H5N1 virus was detected in poultry samples, was same clade and highly homogenous with the virus was detected in the mother.

Conclusions

This was the first documented a live birth from a pregnant woman infected with influenza A/H5N1 virus. Intensive studies are needed to better understand mother‐to‐child transmission of influenza A/H5N1 virus.

Hormonal Regulation of Physiology, Innate Immunity and Antibody Response to H1N1 Influenza Virus Infection During Pregnancy

In 2009, the H1N1 swine flu pandemic highlighted the vulnerability of pregnant women to influenza viral infection. Pregnant women infected with influenza A virus were at increased risk of hospitalization and severe acute respiratory distress syndrome (ARDS), which is associated with high mortality, while their newborns had an increased risk of pre-term birth or low birth weight. Pregnant women have a unique immunological profile modulated by the sex hormones required to maintain pregnancy, namely progesterone and estrogens. The role of these hormones in coordinating maternal immunotolerance in uterine tissue and cellular subsets has been well researched; however, these hormones have wide-ranging effects outside the uterus in modulating the immune response to disease. In this review, we compile research findings in the clinic and in animal models that elaborate on the unique features of H1N1 influenza A viral pathogenesis during pregnancy, the crosstalk between innate immune signaling and hormonal regulation during pregnancy, and the role of pregnancy hormones in modulating cellular responses to influenza A viral infection at mid-gestation. We highlight the ways in which lung architecture and function is stressed by pregnancy, increasing baseline inflammation prior to infection. We demonstrate that infection disrupts progesterone production and upregulates inflammatory mediators, such as cyclooxygenase-2 (COX-2) and prostaglandins, resulting in pre-term labor and spontaneous abortions. Lastly, we profile the ways in which pregnancy alters innate and adaptive cellular immune responses to H1N1 influenza viral infection, and the ways in which these protect fetal development at the expense of effective long-term immune memory. Thus, we highlight advancements in the field of reproductive immunology in response to viral infection and illustrate how that knowledge might be used to develop more effective post-infection therapies and vaccination strategies.

Australian caregivers' perceptions of influenza vaccination in pregnancy: A mixed methods exploration

BACKGROUND

Pregnant women and their unborn children are at high risk from both pandemic and seasonal influenza.

AIM

To explore views about influenza vaccination during pregnancy, in a pandemic and immediate post-pandemic context, among mothers and other carers of young children.

METHODS

In a mixed methods study, caregivers from 16 childcare centres in Sydney, Australia, were surveyed in November and December 2009, and interviews were conducted with caregivers from six childcare centres between June 2009 and May 2011.

FINDINGS

Emerging themes from 41 interviews conducted with mothers included: 'pregnancy as a protected state', 'risk negotiation' and 'centrality of healthcare worker interaction'. Of 972 surveys distributed, 431 were completed (a response rate of 44%). Respondents perceived pandemic influenza risks to be greater for pregnant women than for their unborn children. Only 2% (9/383) of women reported being vaccinated against swine flu during pregnancy and 45% (168/383) indicated intent to receive swine flu vaccination in a future pregnancy.

DISCUSSION

The low rates of maternal influenza vaccination revealed in this study contrast to recent gains in vaccine uptake. Vaccination decision-making in pregnancy can be complex and contextually driven for some women. Healthcare workers, including midwives, have a key role in addressing women's concerns about maternal influenza vaccination in both pandemic and interpandemic periods.

CONCLUSIONS

Policy makers need to be cognisant of women's concerns and develop resources for both pregnant women and healthcare workers as part of both future pandemic planning and seasonal vaccination efforts.

Epidemiological and virological differences in human clustered and sporadic infections with avian influenza A H7N9

BACKGROUND

Previous research has suggested that avian influenza A H7N9 has a greater potential pandemic risk than influenza A H5N1. This research investigated the difference in human clustered and sporadic cases of H7N9 virus and estimated the relative risk of clustered infections.

METHODS

Comparative epidemiology and virology studies were performed among 72 sporadic confirmed cases, 17 family clusters (FCs) caused by human-to-human transmission, and eight live bird market clusters (LCs) caused by co-exposure to the poultry environment.

RESULTS

The case fatality of FCs, LCs and sporadic cases (36%, 26%, and 29%, respectively) did not differ among the three groups (p>0.05). The average age (36 years, 60 years, and 58 years), co-morbidities (31%, 60%, and 54%), exposure to birds (72%, 100%, and 83%), and H7N9-positive rate (20%, 64%, and 35%) in FCs, LCs, and sporadic cases, respectively, differed significantly (p<0.05). These higher risks were associated with increased mortality. There was no difference between primary and secondary cases in LCs (p>0.05). However, exposure to a person with confirmed avian influenza A H7N9 (primary 12% vs. secondary 95%), history of visiting a live bird market (100% vs. 59%), multiple exposures (live bird exposure and human-to-human transmission history) (12% vs. 55%), and median days from onset to antiviral treatment (6 days vs. 3 days) differed significantly between primary and secondary cases in FCs (p<0.05). Mild cases were found in 6% of primary cases vs. 32% of secondary cases in FCs (p<0.05). Twenty-five isolates from the three groups showed 99.1-99.9% homology and increased human adaptation.

CONCLUSIONS

There was no statistical difference in the case fatality rate and limited transmission between FCs and LCs. However, the severity of the primary cases in FCs was much higher than that of the secondary cases due to the older age and greater underlying disease of the latter patients.