The threat of avian influenza a (H5N1): part II: Clues to pathogenicity and pathology

14-Deoxy-11,12-dehydroandrographolide exerts anti-influenza A virus activity and inhibits replication of H5N1 virus by restraining nuclear export of viral ribonucleoprotein complexes

The highly pathogenic avian influenza H5N1 virus has become a worldwide public health threat, and current antiviral therapies have limited activity against the emerging, resistant influenza viruses. Therefore, effective drugs with novel targets against influenza A viruses, H5N1 strains in particular, should be developed. In the present study, 14-deoxy-11,12-dehydroandrographolide (DAP), a major component of the traditional Chinese medicine Andrographis paniculata, exerted potent anti-influenza A virus activity against A/chicken/Hubei/327/2004 (H5N1), A/duck/Hubei/XN/2007 (H5N1), A/PR/8/34 (H1N1), A/NanChang/08/2010 (H1N1) and A/HuNan/01/2014 (H3N2) in vitro. To elucidate the underlying mechanisms, a series of experiments was conducted using A/chicken/Hubei/327/2004 (H5N1) as an example. Our results demonstrated that DAP strongly inhibited H5N1 replication by reducing the production of viral nucleoprotein (NP) mRNA, NP and NS1proteins, whereas DAP had no effect on the absorption and release of H5N1 towards/from A549 cells. DAP also effectively restrained the nuclear export of viral ribonucleoprotein (vRNP) complexes. This inhibitory effect ought to be an important anti-H5N1 mechanism of DAP. Meanwhile, DAP significantly reduced the upregulated expression of all the tested proinflammatory cytokines (TNF-α, IL-6, IL-8, IFN-α, IL-1β and IFN-β) and chemokines (CXCL-10 and CCL-2) stimulated by H5N1. Overall results suggest that DAP impairs H5N1 replication at least in part by restraining nuclear export of vRNP complexes, and the inhibition of viral replication leads to a subsequent decrease of the intense proinflammatory cytokine/chemokine expression. In turn, the effect of modification of the host excessive immune response may contribute to overcoming H5N1. To our knowledge, this study is the first to reveal the antiviral and anti-inflammatory activities of DAP in vitro against H5N1 influenza A virus infection.

N-acetyl-l-cystine (NAC) protects against H9N2 swine influenza virus-induced acute lung injury

The antioxidant N-acetyl-l-cysteine (NAC) had been shown to inhibit replication of seasonal human influenza A viruses. Here, the effects of NAC on H9N2 swine influenza virus-induced acute lung injury (ALI) were investigated in mice. BALB/c mice were inoculated intranasally with 10⁷ 50% tissue culture infective doses (TCID₅₀) of A/swine/HeBei/012/2008/(H9N2) viruses with or without NAC treatments to induce ALI model. The result showed that pulmonary inflammation, pulmonary edema, MPO activity, total cells, neutrophils, macrophages, TNF-α, IL-6, IL-1β and CXCL-10 in BALF were attenuated by NAC. Moreover, our data showed that NAC significantly inhibited the levels of TLR4 protein and TLR4 mRNA in the lungs. Pharmacological inhibitors of TLR4 (E5564) exerted similar effects like those determined for NAC in H9N2 swine influenza virus-infected mice. These results suggest that antioxidants like NAC represent a potential additional treatment option that could be considered in the case of an influenza A virus pandemic.

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NAC protects against H9N2 swine influenza virus-induced acute lung injury (ALI).

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NAC protects against acute lung injury by inactivation of TLR4.

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Eritoran (E5564), a TLR4 antagonist, also protects against acute lung injury.

Tropism of avian influenza A (H5N1) virus to mesenchymal stem cells and CD34+ hematopoietic stem cells

The presence of abnormal hematologic findings such as lymphopenia, thrombocytopenia, and pancytopenia were diagnosed in severe cases of avian influenza A H5N1. Whether direct viral dissemination to bone marrow (BM) cells causes this phenomenon remains elusive. We explore the susceptibility of the two stem cell types; hematopoietic stem cells (HSCs) and mesenchymal stromal cells (MSCs) isolated from human BM cells or cord blood, to infection with avian H5N1 viruses. For the first time, we demonstrated that the H5N1 virus could productively infect and induce cell death in both human stem cell types. In contrast, these activities were not observed upon human influenza virus infection. We also determined whether infection affects the immunomodulatory function of MSCs. We noted a consequent dysregulation of MSC-mediated immune modulation as observed by high cytokine and chemokine production in H5N1 infected MSCs and monocytes cocultures. These findings provide a better understanding of H5N1 pathogenesis in terms of broad tissue tropism and systemic spread.

Glycyrrhizin exerts antioxidative effects in H5N1 influenza A virus-infected cells and inhibits virus replication and pro-inflammatory gene expression

Glycyrrhizin is known to exert antiviral and anti-inflammatory effects. Here, the effects of an approved parenteral glycyrrhizin preparation (Stronger Neo-Minophafen C) were investigated on highly pathogenic influenza A H5N1 virus replication, H5N1-induced apoptosis, and H5N1-induced pro-inflammatory responses in lung epithelial (A549) cells. Therapeutic glycyrrhizin concentrations substantially inhibited H5N1-induced expression of the pro-inflammatory molecules CXCL10, interleukin 6, CCL2, and CCL5 (effective glycyrrhizin concentrations 25 to 50 µg/ml) but interfered with H5N1 replication and H5N1-induced apoptosis to a lesser extent (effective glycyrrhizin concentrations 100 µg/ml or higher). Glycyrrhizin also diminished monocyte migration towards supernatants of H5N1-infected A549 cells. The mechanism by which glycyrrhizin interferes with H5N1 replication and H5N1-induced pro-inflammatory gene expression includes inhibition of H5N1-induced formation of reactive oxygen species and (in turn) reduced activation of NFκB, JNK, and p38, redox-sensitive signalling events known to be relevant for influenza A virus replication. Therefore, glycyrrhizin may complement the arsenal of potential drugs for the treatment of H5N1 disease.

Comparison of adjuvant efficacy of chitosan and aluminum hydroxide for intraperitoneally administered inactivated influenza H5N1 vaccine

A safe and effective adjuvant is important to develop vaccines against highly pathogenic avian influenza virus. Chitosan, a derivative from the natural amino polysaccharide chitin, has been proved to be an effective adjuvant for inactivated influenza virus vaccine. In this study, protective immunity in mice provided by chitosan-adjuvanted inactivated H5N1 vaccine was compared with that from an aluminum hydroxide-adjuvanted one. Mice were injected intraperitoneally once or twice with various dosages of inactivated vaccine alone or in combination with an adjuvant (chitosan or aluminum hydroxide). To test the immunization effect, mice were challenged with a lethal dose of H5N1 virus. The results showed that the adjuvanted vaccines were more effective than adjuvant-free ones in inducing humoral immune responses and protecting mice against lethal challenge. Chitosan was comparable to the alum adjuvant in efficacy. These findings indicated that chitosan might be a candidate adjuvant for parenteral administration of inactivated influenza vaccines.

Glycyrrhizin inhibits highly pathogenic H5N1 influenza A virus-induced pro-inflammatory cytokine and chemokine expression in human macrophages

Hypercytokinaemia is thought to contribute to highly pathogenic H5N1 influenza A virus disease. Glycyrrhizin is known to exert immunomodulatory and anti-inflammatory effects and therefore a candidate drug for the control of H5N1-induced pro-inflammatory gene expression. Here, the effects of an approved parenteral glycyrrhizin preparation were investigated on H5N1 virus replication, H5N1-induced pro-inflammatory responses, and H5N1-induced apoptosis in human monocyte-derived macrophages. Glycyrrhizin 100 μg/ml, a therapeutically achievable concentration, impaired H5N1-induced production of CXCL10, interleukin 6, and CCL5 and inhibited H5N1-induced apoptosis but did not interfere with H5N1 replication. Global inhibition of immune responses may result in the loss of control of virus replication by cytotoxic immune cells including natural killer cells and cytotoxic CD8(+) T-lymphocytes. Notably, glycyrrhizin concentrations that inhibited H5N1-induced pro-inflammatory gene expression did not affect cytolytic activity of natural killer cells. Since H5N1-induced hypercytokinaemia is considered to play an important role within H5N1 pathogenesis, glycyrrhizin may complement the arsenal of potential drugs for the treatment of H5N1 disease.

An influenza A H1N1 virus revival - pandemic H1N1/09 virus

In April 2009, a novel H1N1 influenza A virus, the so-called pandemic H1N1/09 virus (former designations include swine influenza, novel influenza, swine-origin influenza A [H1N1] virus [S-OIV], Mexican flu, North American Flu) was identified in Mexico. The virus has since spread throughout the world and caused an influenza pandemic as defined by the criteria of the World Health Organization. This represents the first influenza A virus pandemic since the emergence of H3N2 (''Hong Kong'' Flu) in 1968. Vaccine production has started, and vaccines are expected to become available during the course of 2009. Although the pandemic H1N1/09 virus originates from the triple-reassortant swine influenza (H1) virus circulating in North American pigs, it is not epidemic in pigs. Although the H1N1/09 virus pandemic is currently mild, concerns remain that it may become more aggressive during spreading. The distribution of proper information to the public on the status of the H1N1/09 virus pandemic will be important to achieve a broad awareness of the potential risks and the optimum code of behavior during the pandemic. Here, the features of pandemic H1N1/09 virus are discussed within the framework of knowledge gained from previous influenza A virus pandemics.

N-acetyl-L-cysteine (NAC) inhibits virus replication and expression of pro-inflammatory molecules in A549 cells infected with highly pathogenic H5N1 influenza A virus

The antioxidant N-acetyl-L-cysteine (NAC) had been shown to inhibit replication of seasonal human influenza A viruses. Here, the effects of NAC on virus replication, virus-induced pro-inflammatory responses and virus-induced apoptosis were investigated in H5N1-infected lung epithelial (A549) cells. NAC at concentrations ranging from 5 to 15 mM reduced H5N1-induced cytopathogenic effects (CPEs), virus-induced apoptosis and infectious viral yields 24 h post-infection. NAC also decreased the production of pro-inflammatory molecules (CXCL8, CXCL10, CCL5 and interleukin-6 (IL-6)) in H5N1-infected A549 cells and reduced monocyte migration towards supernatants of H5N1-infected A549 cells. The antiviral and anti-inflammatory mechanisms of NAC included inhibition of activation of oxidant sensitive pathways including transcription factor NF-kappaB and mitogen activated protein kinase p38. Pharmacological inhibitors of NF-kappaB (BAY 11-7085) or p38 (SB203580) exerted similar effects like those determined for NAC in H5N1-infected cells. The combination of BAY 11-7085 and SB203580 resulted in increased inhibitory effects on virus replication and production of pro-inflammatory molecules relative to either single treatment. NAC inhibits H5N1 replication and H5N1-induced production of pro-inflammatory molecules. Therefore, antioxidants like NAC represent a potential additional treatment option that could be considered in the case of an influenza A virus pandemic.

The clinical value of neutrophil extracellular traps

Neutrophil extracellular traps (NETs) have recently been discovered as a central part of antimicrobial innate immunity. In the meanwhile, evidence accumulated that NETs are also generated upon non-infectious stimuli in various clinical settings. In acute or chronic inflammatory disorders aberrantly enhanced NET formation and/or decreased NET degradation seems to correlate with disease outcome. This review summarizes current knowledge about the relation of NETs in a broad spectrum of clinical settings. Specifically, we focus on the importance of NETs as a predictive marker in severely ill patients and further, we speculate about the potential pathophysiology of NETs.

Novel swine-origin influenza A virus in humans: another pandemic knocking at the door

Influenza A viruses represent a continuous pandemic threat. In April 2009, a novel influenza A virus, the so-called swine-origin influenza A (H1N1) virus (S-OIV), was identified in Mexico. Although S-OIV originates from triple-reassortant swine influenza A (H1) that has been circulating in North American pig herds since the end of the 1990s, S-OIV is readily transmitted between humans but is not epidemic in pigs. After its discovery, S-OIV rapidly spread throughout the world within few weeks. In this review, we sum up the current situation and put it into the context of the current state of knowledge of influenza and influenza pandemics. Some indications suggest that a pandemic may be mild but even "mild" pandemics can result in millions of deaths. However, no reasonable forecasts how this pandemic may develop can be made at this time. Despite stockpiling by many countries and WHO, antiviral drugs will be limited in case of pandemic and resistances may emerge. Effective vaccines are regarded to be crucial for the control of influenza pandemics. However, production capacities are restricted and development/production of a S-OIV vaccine will interfere with manufacturing of seasonal influenza vaccines. The authors are convinced that S-OIV should be taken seriously as pandemic threat and underestimation of the menace by S-OIV to be by far more dangerous than its overestimation.

Protection and virus shedding of falcons vaccinated against highly pathogenic avian influenza A virus (H5N1)

Virus shedding by vaccinated birds was markedly reduced.

Because fatal infections with highly pathogenic avian influenza A (HPAI) virus subtype H5N1 have been reported in birds of prey, we sought to determine detailed information about the birds’ susceptibility and protection after vaccination. Ten falcons vaccinated with an inactivated influenza virus (H5N2) vaccine seroconverted. We then challenged 5 vaccinated and 5 nonvaccinated falcons with HPAI (H5N1). All vaccinated birds survived; all unvaccinated birds died within 5 days. For the nonvaccinated birds, histopathologic examination showed tissue degeneration and necrosis, immunohistochemical techniques showed influenza virus antigen in affected tissues, and these birds shed high levels of infectious virus from the oropharynx and cloaca. Vaccinated birds showed no influenza virus antigen in tissues and shed virus at lower titers from the oropharynx only. Vaccination could protect these valuable birds and, through reduced virus shedding, reduce risk for transmission to other avian species and humans.

The threat of avian influenza A (H5N1). Part IV: development of vaccines

Among emerging and re-emerging infectious diseases, influenza constitutes one of the major threats to mankind. In this review series epidemiologic, virologic and pathologic concerns raised by infections of humans with avian influenza virus A/H5N1 are discussed. This fourth part focuses on vaccine development. Several phase I clinical studies with vaccines against H5 viruses have demonstrated limited efficacy compared to seasonal influenza vaccines. To induce protective immunity two immunisations with increased amounts of H5N1 vaccine were required. Novel vaccination strategies that are egg- and adjuvant-independent, broadly cross-reactive and long-lasting are highly desirable.

The threat of avian influenza A (H5N1). Part III: antiviral therapy

Among emerging and re-emerging infectious diseases, influenza constitutes one of the major threats to mankind. In this review series epidemiologic, virologic and pathologic concerns raised by infections of humans with avian influenza virus A/H5N1 as well as treatment options are discussed. The third part discusses therapeutic options. Neuraminidase (NA) inhibitors are the most promising agents despite uncertainty about efficacy. Dosage increase, prolonged treatment or combination therapies may increase treatment efficacy and/or inhibit resistance formation. Immune system dysregulation contributes to H5N1 disease. Although current evidence does not support the use of anti-inflammatory drugs beneficial effects cannot be excluded at later disease stages.