1
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Chon I, Wagatsuma K, Saito R, Tang JW, Isamu S, Suzuki E, Shirahige Y, Kawashima T, Minato M, Kodo N, Masaki H, Hamabata H, Yoshioka S, Ichikawa Y, Sun Y, Li J, Otoguto T, Watanabe H. Detection of influenza A(H3N2) viruses with polymerase acidic subunit substitutions after and prior to baloxavir marboxil treatment during the 2022-2023 influenza season in Japan. Antiviral Res 2024; 229:105956. [PMID: 38969237 DOI: 10.1016/j.antiviral.2024.105956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 06/29/2024] [Accepted: 07/02/2024] [Indexed: 07/07/2024]
Abstract
Baloxavir marboxil (baloxavir), approved as an anti-influenza drug in Japan in March 2018, can induce reduced therapeutic effectiveness due to PA protein substitutions. We assessed PA substitutions in clinical samples from influenza-infected children and adults pre- and post-baloxavir treatment, examining their impact on fever and symptom duration. During the 2022-2023 influenza season, the predominant circulating influenza subtype detected by cycling-probe RT-PCR was A(H3N2) (n = 234), with a minor circulation of A(H1N1)pdm09 (n = 10). Of the 234 influenza A(H3N2) viruses collected prior to baloxavir treatment, 2 (0.8%) viruses carry PA/I38T substitution. One virus was collected from a toddler and one from an adult, indicating the presence of viruses with reduced susceptibility to baloxavir, without prior exposure to the drug. Of the 54 paired influenza A(H3N2) viruses collected following baloxavir treatment, 8 (14.8%) viruses carried E23 K/G, or I38 M/T substitutions in PA. Variant calling through next-generation sequencing (NGS) showed varying proportions (6-100 %), a polymorphism and a mixture of PA/E23 K/G, and I38 M/T substitutions in the clinical samples. These eight viruses were obtained from children aged 7-14 years, with a median fever duration of 16.7 h and a median symptom duration of 93.7 h, which were similar to those of the wild type. However, the delayed viral clearance associated with the emergence of PA substitutions was observed. No substitutions conferring resistance to neuraminidase inhibitors were detected in 37 paired samples collected before and following oseltamivir treatment. These findings underscore the need for ongoing antiviral surveillance, informing public health strategies and clinical antiviral recommendations for seasonal influenza.
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Affiliation(s)
- Irina Chon
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
| | - Keita Wagatsuma
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Reiko Saito
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Julian W Tang
- Respiratory Sciences, University of Leicester, Leicester, UK; Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | | | | | | | | | | | | | - Sayaka Yoshioka
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yusuke Ichikawa
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yuyang Sun
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Jiaming Li
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Teruhime Otoguto
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hisami Watanabe
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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2
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Chen D, Su W, Choy KT, Chu YS, Lin CH, Yen HL. High throughput profiling identified PA-L106R amino acid substitution in A(H1N1)pdm09 influenza virus that confers reduced susceptibility to baloxavir in vitro. Antiviral Res 2024; 229:105961. [PMID: 39002800 DOI: 10.1016/j.antiviral.2024.105961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 07/15/2024]
Abstract
Baloxavir acid (BXA) is a pan-influenza antiviral that targets the cap-dependent endonuclease of the polymerase acidic (PA) protein required for viral mRNA synthesis. To gain a comprehensive understanding on the molecular changes associated with reduced susceptibility to BXA and their fitness profile, we performed a deep mutational scanning at the PA endonuclease domain of an A (H1N1)pdm09 virus. The recombinant virus libraries were serially passaged in vitro under increasing concentrations of BXA followed by next-generation sequencing to monitor PA amino acid substitutions with increased detection frequencies. Enriched PA amino acid changes were each introduced into a recombinant A (H1N1)pdm09 virus to validate their effect on BXA susceptibility and viral replication fitness in vitro. The I38 T/M substitutions known to confer reduced susceptibility to BXA were invariably detected from recombinant virus libraries within 5 serial passages. In addition, we identified a novel L106R substitution that emerged in the third passage and conferred greater than 10-fold reduced susceptibility to BXA. PA-L106 is highly conserved among seasonal influenza A and B viruses. Compared to the wild-type virus, the L106R substitution resulted in reduced polymerase activity and a minor reduction of the peak viral load, suggesting the amino acid change may result in moderate fitness loss. Our results support the use of deep mutational scanning as a practical tool to elucidate genotype-phenotype relationships, including mapping amino acid substitutions with reduced susceptibility to antivirals.
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Affiliation(s)
- Dongdong Chen
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wen Su
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ka-Tim Choy
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yan Sing Chu
- Centre for PanorOmic Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Chi Ho Lin
- Centre for PanorOmic Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Hui-Ling Yen
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
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3
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Andreev K, Jones JC, Seiler P, Kandeil A, Webby RJ, Govorkova EA. Genotypic and phenotypic susceptibility of emerging avian influenza A viruses to neuraminidase and cap-dependent endonuclease inhibitors. Antiviral Res 2024; 229:105959. [PMID: 38986873 PMCID: PMC11466321 DOI: 10.1016/j.antiviral.2024.105959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/01/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
Avian influenza outbreaks, including ones caused by highly pathogenic A(H5N1) clade 2.3.4.4b viruses, have devastated animal populations and remain a threat to humans. Risk elements assessed for emerging influenza viruses include their susceptibility to approved antivirals. Here, we screened >20,000 neuraminidase (NA) or polymerase acidic (PA) protein sequences of potentially pandemic A(H5Nx), A(H7Nx), and A(H9N2) viruses that circulated globally in 2010-2023. The frequencies of NA or PA substitutions associated with reduced inhibition (RI) or highly reduced inhibition (HRI) by NA inhibitors (NAIs) (oseltamivir, zanamivir) or a cap-dependent endonuclease inhibitor (baloxavir) were low: 0.60% (137/22,713) and 0.62% (126/20,347), respectively. All tested subtypes were susceptible to NAIs and baloxavir at sub-nanomolar concentrations. A(H9N2) viruses were the most susceptible to oseltamivir, with IC50s 3- to 4-fold lower than for other subtypes (median IC50: 0.18 nM; n = 22). NA-I222M conferred RI of A(H5N1) viruses by oseltamivir (with a 26-fold IC50 increase), but NA-S246N did not reduce inhibition. PA-E23G, PA-K34R, PA-I38M/T, and the previously unreported PA-A36T caused RI by baloxavir in all subtypes tested. Avian A(H9N2) viruses endemic in Egyptian poultry predominantly acquired PA-I38V, which causes only a <3-fold decrease in the baloxavir EC50 and fails to meet the RI criteria. PA-E199A/D in A(H7Nx) and A(H9N2) viruses caused a 2- to 4-fold decrease in EC50 (close to the borderline for RI) and should be closely monitored. Our data indicate antiviral susceptibility is high among avian influenza A viruses with pandemic potential and present novel markers of resistance to existing antiviral interventions.
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Affiliation(s)
- Konstantin Andreev
- Department of Host-Microbe Interactions, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeremy C Jones
- Department of Host-Microbe Interactions, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Patrick Seiler
- Department of Host-Microbe Interactions, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ahmed Kandeil
- Department of Host-Microbe Interactions, St. Jude Children's Research Hospital, Memphis, TN, USA; Center of Scientific Excellence for Influenza Viruses, National Research Centre, Giza, 12622, Egypt
| | - Richard J Webby
- Department of Host-Microbe Interactions, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Elena A Govorkova
- Department of Host-Microbe Interactions, St. Jude Children's Research Hospital, Memphis, TN, USA.
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4
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Chiarelli A, Dobrovolny H. Viral Rebound After Antiviral Treatment: A Mathematical Modeling Study of the Role of Antiviral Mechanism of Action. Interdiscip Sci 2024:10.1007/s12539-024-00643-w. [PMID: 39033482 DOI: 10.1007/s12539-024-00643-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 07/23/2024]
Abstract
The development of antiviral treatments for SARS-CoV-2 was an important turning point for the pandemic. Availability of safe and effective antivirals has allowed people to return back to normal life. While SARS-CoV-2 antivirals are highly effective at preventing severe disease, there have been concerning reports of viral rebound in some patients after cessation of antiviral treatment. In this study, we use a mathematical model of viral infection to study the potential of different antivirals to prevent viral rebound. We find that antivirals that block production are most likely to result in viral rebound if the treatment time course is not sufficiently long. Since these antivirals do not prevent infection of cells, cells continue to be infected during treatment. When treatment is stopped, the infected cells will begin producing virus at the usual rate. Antivirals that prevent infection of cells are less likely to result in viral rebound since cells are not being infected during treatment. This study highlights the role of antiviral mechanism of action in increasing or reducing the probability of viral rebound.
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Affiliation(s)
- Aubrey Chiarelli
- Department of Physics and Astronomy, Texas Christian University, Fort Worth, 76129, USA
| | - Hana Dobrovolny
- Department of Physics and Astronomy, Texas Christian University, Fort Worth, 76129, USA.
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5
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Kohlbrand A, Stokes RW, Sankaran B, Cohen SM. Structural Studies of Inhibitors with Clinically Relevant Influenza Endonuclease Variants. Biochemistry 2024; 63:264-272. [PMID: 38190441 PMCID: PMC10851415 DOI: 10.1021/acs.biochem.3c00536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 01/10/2024]
Abstract
Vital to the treatment of influenza is the use of antivirals such as Oseltamivir (Tamiflu) and Zanamivir (Relenza); however, antiviral resistance is becoming an increasing problem for these therapeutics. The RNA-dependent RNA polymerase acidic N-terminal (PAN) endonuclease, a critical component of influenza viral replication machinery, is an antiviral target that was recently validated with the approval of Baloxavir Marboxil (BXM). Despite its clinical success, BXM has demonstrated susceptibility to resistance mutations, specifically the I38T, E23K, and A36 V mutants of PAN. To better understand the effects of these mutations on BXM resistance and improve the design of more robust therapeutics, this study examines key differences in protein-inhibitor interactions with two inhibitors and the I38T, E23K, and A36 V mutants. Differences in inhibitor binding were evaluated by measuring changes in binding to PAN using two biophysical methods. The binding mode of two distinct inhibitors was determined crystallographically with both wild-type and mutant forms of PAN. Collectively, these studies give some insight into the mechanism of antiviral resistance of these mutants.
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Affiliation(s)
- Alysia
J. Kohlbrand
- Department
of Chemistry and Biochemistry, University
of California, La Jolla, California 92093, United States
| | - Ryjul W. Stokes
- Department
of Chemistry and Biochemistry, University
of California, La Jolla, California 92093, United States
| | - Banumathi Sankaran
- The
Berkeley Center for Structural Biology, Advanced Light Source, Lawrence Berkeley National Laboratory, Berkeley, California 94720, United States
| | - Seth M. Cohen
- Department
of Chemistry and Biochemistry, University
of California, La Jolla, California 92093, United States
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6
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Hickerson BT, Huang BK, Petrovskaya SN, Ilyushina NA. Genomic Analysis of Influenza A and B Viruses Carrying Baloxavir Resistance-Associated Substitutions Serially Passaged in Human Epithelial Cells. Viruses 2023; 15:2446. [PMID: 38140689 PMCID: PMC10748225 DOI: 10.3390/v15122446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Baloxavir marboxil (baloxavir) is an FDA-approved inhibitor of the influenza virus polymerase acidic (PA) protein. Here, we used next-generation sequencing to compare the genomic mutational profiles of IAV H1N1 and H3N2, and IBV wild type (WT) and mutants (MUT) viruses carrying baloxavir resistance-associated substitutions (H1N1-PA I38L, I38T, and E199D; H3N2-PA I38T; and IBV-PA I38T) during passaging in normal human bronchial epithelial (NHBE) cells. We determined the ratio of nonsynonymous to synonymous nucleotide mutations (dN/dS) and identified the location and type of amino acid (AA) substitutions that occurred at a frequency of ≥30%. We observed that IAV H1N1 WT and MUT viruses remained relatively stable during passaging. While the mutational profiles for IAV H1N1 I38L, I38T, and E199D, and IBV I38T MUTs were relatively similar after each passage compared to the respective WTs, the mutational profile of the IAV H3N2 I38T MUT was significantly different for most genes compared to H3N2 WT. Our work provides insight into how baloxavir resistance-associated substitutions may impact influenza virus evolution in natural settings. Further characterization of the potentially adaptive mutations identified in this study is needed.
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Affiliation(s)
- Brady T. Hickerson
- Division of Biotechnology Review and Research II, Food and Drug Administration, Silver Spring, MD 20993, USA
| | - Bruce K. Huang
- Division of Biotechnology Review and Research II, Food and Drug Administration, Silver Spring, MD 20993, USA
| | - Svetlana N. Petrovskaya
- Division of Biotechnology Review and Research III, Food and Drug Administration, Silver Spring, MD 20993, USA
| | - Natalia A. Ilyushina
- Division of Biotechnology Review and Research II, Food and Drug Administration, Silver Spring, MD 20993, USA
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7
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Luo D, Ye Q, Li RT, Zhou HY, Guo JJ, Zhao SQ, Zhang S, Jiang T, Deng YQ, Qin CF. PA-E18G substitution in influenza A virus confers resistance to ZX-7101, a cap-dependent endonuclease inhibitor. Virol Sin 2023; 38:559-567. [PMID: 37290559 PMCID: PMC10436051 DOI: 10.1016/j.virs.2023.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023] Open
Abstract
Cap-dependent endonuclease (CEN) in the polymerase acidic protein (PA) of influenza A virus (IAV) represents a promising drug target due to its critical role in viral gene transcription. The CEN inhibitor, baloxavir marboxil (BXM), was approved in Japan and the US in 2018 and several other countries subsequently. Along with the clinical use of BXM, the emergence and spread of IAV variants with reduced susceptibility to BXM have aroused serious concern. Herein, we comprehensively characterized the in vitro and in vivo antiviral activities of ZX-7101A, an analogue of BXM. The active form of prodrug ZX-7101 showed broad-spectrum antiviral potency against various IAV subtypes, including pH1N1, H3N2, H7N9 and H9N2, in MDCK cells, and the 50% effective concentration (EC50) was calculated to nanomole level and comparable to that of baloxavir acid (BXA), the active form of BXM. Furthermore, in vivo assays showed that administration of ZX-7101A conferred significant protection against lethal pH1N1 challenge in mice, with reduced viral RNA loads and alleviated pulmonary damage. Importantly, serial passaging of H1N1 virus in MDCK cells under selection pressure of ZX-7101 led to a resistant variant at the 15th passage. Reverse genetic and sequencing analysis demonstrated that a single E18G substitution in the PA subunit contributed to the reduced susceptibility to both ZX-7101 and BXA. Taken together, our results not only characterized a new CEN inhibitor of IAV but also identified a novel amino acid substitution responsible for CEN inhibitor resistance, which provides critical clues for future drug development and drug resistance surveillance.
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Affiliation(s)
- Dan Luo
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China
| | - Qing Ye
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China
| | - Rui-Ting Li
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China
| | - Hang-Yu Zhou
- State Key Laboratory of Medical Molecular Biology, Suzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Suzhou 215123, China
| | - Jing-Jing Guo
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China
| | - Suo-Qun Zhao
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China
| | - Sen Zhang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China
| | - Tao Jiang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China
| | - Yong-Qiang Deng
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China.
| | - Cheng-Feng Qin
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Academy of Military Medical Sciences, Beijing 100071, China.
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8
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Hickerson BT, Petrovskaya SN, Dickensheets H, Donnelly RP, Ince WL, Ilyushina NA. Impact of Baloxavir Resistance-Associated Substitutions on Influenza Virus Growth and Drug Susceptibility. J Virol 2023; 97:e0015423. [PMID: 37404185 PMCID: PMC10373543 DOI: 10.1128/jvi.00154-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/10/2023] [Indexed: 07/06/2023] Open
Abstract
Baloxavir marboxil (baloxavir) is a recently FDA-approved influenza virus polymerase acidic (PA) endonuclease inhibitor. Several PA substitutions have been demonstrated to confer reduced susceptibility to baloxavir; however, their impacts on measurements of antiviral drug susceptibility and replication capacity when present as a fraction of the viral population have not been established. We generated recombinant A/California/04/09 (H1N1)-like viruses (IAV) with PA I38L, I38T, or E199D substitutions and B/Victoria/504/2000-like virus (IBV) with PA I38T. These substitutions reduced baloxavir susceptibility by 15.3-, 72.3-, 5.4-, and 54.5-fold, respectively, when tested in normal human bronchial epithelial (NHBE) cells. We then assessed the replication kinetics, polymerase activity, and baloxavir susceptibility of the wild-type:mutant (WT:MUT) virus mixtures in NHBE cells. The percentage of MUT relative to WT virus necessary to detect reduced baloxavir susceptibility in phenotypic assays ranged from 10% (IBV I38T) to 92% (IAV E199D). While I38T did not alter IAV replication kinetics or polymerase activity, IAV PA I38L and E199D MUTs and the IBV PA I38T MUT exhibited reduced replication levels and significantly altered polymerase activity. Differences in replication were detectable when the MUTs comprised ≥90%, ≥90%, or ≥75% of the population, respectively. Droplet digital PCR (ddPCR) and next-generation sequencing (NGS) analyses showed that WT viruses generally outcompeted the respective MUTs after multiple replication cycles and serial passaging in NHBE cells when initial mixtures contained ≥50% of the WT viruses; however, we also identified potential compensatory substitutions (IAV PA D394N and IBV PA E329G) that emerged and appeared to improve the replication capacity of baloxavir-resistant virus in cell culture. IMPORTANCE Baloxavir marboxil, an influenza virus polymerase acidic endonuclease inhibitor, represents a recently approved new class of influenza antivirals. Treatment-emergent resistance to baloxavir has been observed in clinical trials, and the potential spread of resistant variants could diminish baloxavir effectiveness. Here, we report the impact of the proportion of drug-resistant subpopulations on the ability to detect resistance in clinical isolates and the impact of substitutions on viral replication of mixtures containing both drug-sensitive and drug-resistant variants. We also show that ddPCR and NGS methods can be successfully used for detection of resistant subpopulations in clinical isolates and to quantify their relative abundance. Taken together, our data shed light on the potential impact of baloxavir-resistant I38T/L and E199D substitutions on baloxavir susceptibility and other biological properties of influenza virus and the ability to detect resistance in phenotypic and genotypic assays.
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Affiliation(s)
- Brady T. Hickerson
- Division of Biotechnology Review and Research II, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Svetlana N. Petrovskaya
- Division of Biotechnology Review and Research III, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Harold Dickensheets
- Division of Biotechnology Review and Research II, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Raymond P. Donnelly
- Division of Biotechnology Review and Research II, Food and Drug Administration, Silver Spring, Maryland, USA
| | - William L. Ince
- Division of Antivirals, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Natalia A. Ilyushina
- Division of Biotechnology Review and Research II, Food and Drug Administration, Silver Spring, Maryland, USA
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9
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Lieber CM, Aggarwal M, Yoon JJ, Cox RM, Kang HJ, Sourimant J, Toots M, Johnson SK, Jones CA, Sticher ZM, Kolykhalov AA, Saindane MT, Tompkins SM, Planz O, Painter GR, Natchus MG, Sakamoto K, Plemper RK. 4'-Fluorouridine mitigates lethal infection with pandemic human and highly pathogenic avian influenza viruses. PLoS Pathog 2023; 19:e1011342. [PMID: 37068076 PMCID: PMC10138230 DOI: 10.1371/journal.ppat.1011342] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/27/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023] Open
Abstract
Influenza outbreaks are associated with substantial morbidity, mortality and economic burden. Next generation antivirals are needed to treat seasonal infections and prepare against zoonotic spillover of avian influenza viruses with pandemic potential. Having previously identified oral efficacy of the nucleoside analog 4'-Fluorouridine (4'-FlU, EIDD-2749) against SARS-CoV-2 and respiratory syncytial virus (RSV), we explored activity of the compound against seasonal and highly pathogenic influenza (HPAI) viruses in cell culture, human airway epithelium (HAE) models, and/or two animal models, ferrets and mice, that assess IAV transmission and lethal viral pneumonia, respectively. 4'-FlU inhibited a panel of relevant influenza A and B viruses with nanomolar to sub-micromolar potency in HAE cells. In vitro polymerase assays revealed immediate chain termination of IAV polymerase after 4'-FlU incorporation, in contrast to delayed chain termination of SARS-CoV-2 and RSV polymerase. Once-daily oral treatment of ferrets with 2 mg/kg 4'-FlU initiated 12 hours after infection rapidly stopped virus shedding and prevented transmission to untreated sentinels. Treatment of mice infected with a lethal inoculum of pandemic A/CA/07/2009 (H1N1)pdm09 (pdmCa09) with 4'-FlU alleviated pneumonia. Three doses mediated complete survival when treatment was initiated up to 60 hours after infection, indicating a broad time window for effective intervention. Therapeutic oral 4'-FlU ensured survival of animals infected with HPAI A/VN/12/2003 (H5N1) and of immunocompromised mice infected with pdmCa09. Recoverees were protected against homologous reinfection. This study defines the mechanistic foundation for high sensitivity of influenza viruses to 4'-FlU and supports 4'-FlU as developmental candidate for the treatment of seasonal and pandemic influenza.
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Affiliation(s)
- Carolin M Lieber
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
| | - Megha Aggarwal
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
| | - Jeong-Joong Yoon
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
| | - Robert M Cox
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
| | - Hae-Ji Kang
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
| | - Julien Sourimant
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
| | - Mart Toots
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
| | - Scott K Johnson
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
| | - Cheryl A Jones
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
| | - Zachary M Sticher
- Emory Institute for Drug Development, Emory University, Atlanta, Georgia, United States of America
| | - Alexander A Kolykhalov
- Emory Institute for Drug Development, Emory University, Atlanta, Georgia, United States of America
| | - Manohar T Saindane
- Emory Institute for Drug Development, Emory University, Atlanta, Georgia, United States of America
| | - Stephen M Tompkins
- Center for Vaccines and Immunology, University of Georgia, Athens, Georgia, United States of America
| | - Oliver Planz
- Department of Immunology, Interfaculty Institute for Cell Biology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - George R Painter
- Emory Institute for Drug Development, Emory University, Atlanta, Georgia, United States of America
| | - Michael G Natchus
- Emory Institute for Drug Development, Emory University, Atlanta, Georgia, United States of America
| | - Kaori Sakamoto
- Department of Pathology, College of Veterinary Medicine, University of Georgia, Athens, Georgia, United States of America
| | - Richard K Plemper
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, Georgia, United States of America
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10
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Patel MC, Flanigan D, Feng C, Chesnokov A, Nguyen HT, Elal AA, Steel J, Kondor RJ, Wentworth DE, Gubareva LV, Mishin VP. An optimized cell-based assay to assess influenza virus replication by measuring neuraminidase activity and its applications for virological surveillance. Antiviral Res 2022; 208:105457. [PMID: 36332755 PMCID: PMC10149149 DOI: 10.1016/j.antiviral.2022.105457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Year-round virological characterization of circulating epidemic influenza viruses is conducted worldwide to detect the emergence of viruses that may escape pre-existing immunity or acquire resistance to antivirals. High throughput phenotypic assays are needed to complement the sequence-based analysis of circulating viruses and improve pandemic preparedness. The recent entry of a polymerase inhibitor, baloxavir, into the global market further highlighted this need. Here, we optimized a cell-based assay that considerably streamlines antiviral and antigenic testing by replacing lengthy immunostaining and imaging procedures used in current assay with measuring the enzymatic activity of nascent neuraminidase (NA) molecules expressed on the surface of virus-infected cells. For convenience, this new assay was named IRINA (Influenza Replication Inhibition Neuraminidase-based Assay). IRINA was successfully validated to assess inhibitory activity of baloxavir on virus replication by testing a large set (>150) of influenza A and B viruses, including drug resistant strains and viruses collected during 2017-2022. To test its versatility, IRINA was utilized to evaluate neutralization activity of a broadly reactive human anti-HA monoclonal antibody, FI6, and post-infection ferret antisera, as well as the inhibition of NA enzyme activity by NA inhibitors. Performance of IRINA was tested in parallel using respective conventional assays. IRINA offers an attractive alternative to current phenotypic assays, while maintaining reproducibility and high throughput capacity. Additionally, the improved turnaround time may prove to be advantageous when conducting time sensitive studies, such as investigating a new virus outbreak. This assay can meet the needs of surveillance laboratories by providing a streamlined and cost-effective approach for virus characterization.
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Affiliation(s)
- Mira C Patel
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Daniel Flanigan
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; General Dynamics Information Technology, Atlanta, GA, USA
| | - Chenchen Feng
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Anton Chesnokov
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ha T Nguyen
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Anwar Abd Elal
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Cherokee Nation Integrated Health, L.L.C., Atlanta, GA, USA
| | - John Steel
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rebecca J Kondor
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David E Wentworth
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Larisa V Gubareva
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Vasiliy P Mishin
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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11
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Abstract
This technical report accompanies the recommendations of the American Academy of Pediatrics for the routine use of influenza vaccine and antiviral medications in the prevention and treatment of influenza in children during the 2022 to 2023 season. The American Academy of Pediatrics recommends annual influenza vaccination of all children without medical contraindications starting at 6 months of age. Influenza vaccination is an important strategy for protecting children and the broader community as well as reducing the overall burden of respiratory illnesses when other viruses, including severe acute respiratory syndrome-coronavirus 2, are cocirculating. This technical report summarizes recent influenza seasons, morbidity and mortality in children, vaccine effectiveness, and vaccination coverage, and provides detailed guidance on storage, administration, and implementation. The report also provides a brief background on inactivated and live attenuated influenza vaccine recommendations, vaccination during pregnancy and breastfeeding, diagnostic testing, and antiviral medications for treatment and chemoprophylaxis. Updated information is provided about the 2021 to 2022 influenza season, influenza immunization rates, the effectiveness of influenza vaccination on hospitalization and mortality, available vaccines, guidance for patients with history of severe allergic reactions to prior influenza vaccinations, and strategies to promote vaccine uptake.
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12
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Effect of E23 G/K, F36V, N37T, E119D, and E199G polymerase acidic protein substitutions on the replication and baloxavir susceptibility of influenza B viruses. Antiviral Res 2022; 208:105455. [DOI: 10.1016/j.antiviral.2022.105455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/21/2022]
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13
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Effect of Baloxavir and Oseltamivir in Combination on Infection with Influenza Viruses with PA/I38T or PA/E23K Substitutions in the Ferret Model. mBio 2022; 13:e0105622. [PMID: 35938724 PMCID: PMC9426601 DOI: 10.1128/mbio.01056-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Amino acid substitutions I38T and E23K in the influenza polymerase acidic (PA) protein lead to reduced susceptibility to the influenza antiviral drug baloxavir. The in vivo effectiveness of baloxavir and oseltamivir for treatment of these viruses is currently unknown. Using patient-derived influenza isolates, combination therapy was equally effective as monotherapy in reducing viral titers in the upper respiratory tract of ferrets infected with A(H1N1pdm09)-PA/E23K or A(H3N2)-PA/I38T. When treated with baloxavir plus oseltamivir, infection with a mixture of PA/I38T or PA/E23K and corresponding wild-type virus was characterized by a lower selection of viruses with reduced baloxavir susceptibility over the course of infection compared to baloxavir monotherapy. De novo emergence of the oseltamivir resistance mutation NA/H275Y occurred in ferrets treated with oseltamivir alone but not in ferrets treated with baloxavir plus oseltamivir. Our data suggest that combination therapy with influenza drugs with different mechanisms of action decreased the selection pressure for viruses with reduced drug susceptibility.
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14
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Jones JC, Zagribelnyy B, Pascua PNQ, Bezrukov DS, Barman S, Okda F, Webby RJ, Ivanenkov YA, Govorkova EA. Influenza A virus polymerase acidic protein E23G/K substitutions weaken key baloxavir drug-binding contacts with minimal impact on replication and transmission. PLoS Pathog 2022; 18:e1010698. [PMID: 35830486 PMCID: PMC9312377 DOI: 10.1371/journal.ppat.1010698] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/25/2022] [Accepted: 06/23/2022] [Indexed: 11/19/2022] Open
Abstract
Baloxavir marboxil (BXM) is approved for treating uncomplicated influenza. The active metabolite baloxavir acid (BXA) inhibits cap-dependent endonuclease activity of the influenza virus polymerase acidic protein (PA), which is necessary for viral transcription. Treatment-emergent E23G or E23K (E23G/K) PA substitutions have been implicated in reduced BXA susceptibility, but their effect on virus fitness and transmissibility, their synergism with other BXA resistance markers, and the mechanisms of resistance have been insufficiently studied. Accordingly, we generated point mutants of circulating seasonal influenza A(H1N1)pdm09 and A(H3N2) viruses carrying E23G/K substitutions. Both substitutions caused 2- to 13-fold increases in the BXA EC50. EC50s were higher with E23K than with E23G and increased dramatically (138- to 446-fold) when these substitutions were combined with PA I38T, the dominant BXA resistance marker. E23G/K-substituted viruses exhibited slightly impaired replication in MDCK and Calu-3 cells, which was more pronounced with E23K. In ferret transmission experiments, all viruses transmitted to direct-contact and airborne-transmission animals, with only E23K+I38T viruses failing to infect 100% of animals by airborne transmission. E23G/K genotypes were predominantly stable during transmission events and through five passages in vitro. Thermostable PA–BXA interactions were weakened by E23G/K substitutions and further weakened when combined with I38T. In silico modeling indicated this was caused by E23G/K altering the placement of functionally important Tyr24 in the endonuclease domain, potentially decreasing BXA binding but at some cost to the virus. These data implicate E23G/K, alone or combined with I38T, as important markers of reduced BXM susceptibility, and such mutants could emerge and/or transmit among humans. Baloxavir is a new and potent anti-influenza drug targeting essential functions of viral replication. Currently, the I38T polymerase acidic protein (PA) substitution is the major marker of reduced susceptibility and potential resistance to baloxavir, but the full baloxavir resistance profile remains unclear. Here, we demonstrated that PA E23G/K substitutions alone weaken baloxavir efficacy, but they also synergize with I38T to impair drug activity further. E23G/K substitutions are located close to the binding site of baloxavir and indirectly weaken key drug-binding interactions. This effect has some negative consequences for virus replication, but E23G/K viruses possess the capacity for airborne spread between naïve ferrets, the gold-standard model of human influenza transmission. Therefore, E23G/K viruses have the potential for community spread, which would adversely affect baloxavir clinical implementation. Our study supports ongoing surveillance for circulating human E23G/K viruses, and it may inform design of enhanced baloxavir-like drugs less susceptible to emergence of viral resistance.
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Affiliation(s)
- Jeremy C. Jones
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
- * E-mail:
| | - Bogdan Zagribelnyy
- Department of Chemistry, Lomonosov State University, Moscow, Russian Federation
| | - Philippe Noriel Q. Pascua
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Dmitry S. Bezrukov
- Department of Chemistry, Lomonosov State University, Moscow, Russian Federation
| | - Subrata Barman
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Faten Okda
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Richard J. Webby
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Yan A. Ivanenkov
- Department of Chemistry, Lomonosov State University, Moscow, Russian Federation
| | - Elena A. Govorkova
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
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15
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Takizawa N, Momose F. A novel E198K substitution in the PA gene of influenza A virus with reduced susceptibility to baloxavir acid. Arch Virol 2022; 167:1565-1570. [PMID: 35511288 PMCID: PMC9069958 DOI: 10.1007/s00705-022-05456-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 03/23/2022] [Indexed: 11/02/2022]
Abstract
Baloxavir acid (BXA), the active compound in baloxavir marboxil (BXM), reduces the propagation of influenza A and B viruses by inhibiting the cap-dependent endonuclease activity of the polymerase acidic (PA) subunit. Although BXM has been used to treat influenza virus infections, recently, there has been general concern about the emergence of viruses with low susceptibility to BXA. Here, we identified a novel PA subunit substitution, PA E198K, that reduced susceptibility to BXA. The IC50 of BXA toward influenza A viruses containing PA E198K increased approximately 2- to 6-fold. These findings help to understand the mechanism by which PA substitutions reduce susceptibility to BXA.
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Affiliation(s)
- Naoki Takizawa
- Laboratory of Virology, Institute of Microbial Chemistry (BIKAKEN), 3-14-23 Kamiosaki, Shinagawa-ku, Tokyo, 141-0021, Japan.
| | - Fumitaka Momose
- Satoshi Ōmura Memorial Research Institute and Graduate School for Infection Control, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
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16
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Influenza A virus polymerase acidic protein E23R substitution is a marker of reduced susceptibility to baloxavir. Antiviral Res 2022; 204:105369. [PMID: 35738347 DOI: 10.1016/j.antiviral.2022.105369] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/07/2022] [Accepted: 06/17/2022] [Indexed: 11/02/2022]
Abstract
In our ongoing efforts to identify baloxavir resistance markers, we demonstrated that the influenza A polymerase acidic (PA) protein E23R substitution is genetically stable, increases baloxavir EC50 values (13- to 19-fold vs. wild-type), synergizes with PA I38T, and only modestly decreases viral fitness. E23R is, therefore, a potential threat to baloxavir treatment efficacy.
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17
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Wagatsuma K, Saito R, Chon I, Phyu WW, Fujio K, Kawashima T, Sato I, Saito T, Minato M, Kodo N, Suzuki E, Ono Y, Masaki H, Shirahige Y, Kitano A, Hamabata H, Yuyang S, Jiaming L, Watanabe H. Duration of fever and symptoms in influenza-infected children treated with baloxavir marboxil during the 2019–2020 season in Japan and detection of influenza virus with the PA E23K substitution. Antiviral Res 2022; 201:105310. [DOI: 10.1016/j.antiviral.2022.105310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 12/26/2022]
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18
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Hickerson BT, Adams SE, Barman S, Miller L, Lugovtsev VY, Webby RJ, Ince WL, Donnelly RP, Ilyushina NA. Pleiotropic Effects of Influenza H1, H3, and B Baloxavir-Resistant Substitutions on Replication, Sensitivity to Baloxavir, and Interferon Expression. Antimicrob Agents Chemother 2022; 66:e0000922. [PMID: 35262375 PMCID: PMC9017380 DOI: 10.1128/aac.00009-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/04/2022] [Indexed: 11/20/2022] Open
Abstract
Baloxavir is an anti-influenza endonuclease inhibitor that targets the polymerase acidic (PA) protein of influenza A and B viruses. Our knowledge regarding the pleiotropic effects of baloxavir resistance-associated substitutions is limited. We generated recombinant A/California/04/09 (H1N1)-, A/Hong Kong/218849/2006 (H3N2)-, and B/Victoria/504/2000-like viruses that contained PA substitutions identified in baloxavir clinical trials and surveillance that could potentially be associated with baloxavir resistance. We characterized their susceptibility to baloxavir, impact on polymerase activity, viral growth, and ability to induce interferon (IFN) and IFN-stimulated genes expression in vitro. Four PA substitutions, H1N1 I38L/T, E199D, and B G199R, significantly reduced the sensitivity of the recombinant viruses to baloxavir (14.1-fold). We confirmed our findings by using the luciferase-based ribonucleoprotein minigenome assay and by using virus yield reduction assay in Calu-3 and normal human bronchial epithelial (NHBE) cells. We observed that I38L and E199D resulted in decreased viral replication of the H1N1 wild-type virus (1.4-fold) but the H1N1 I38T and B G199R substitutions did not significantly alter replication capacity in Calu-3 cells. In addition, H1N1 variants with PA I38L/T and E199D induced significantly higher levels of IFNB1 gene expression compared to the wild-type virus (4.2-fold). In contrast, the B variant, G199R, triggered the lowest levels of IFN genes in Calu-3 cells (1.6-fold). Because baloxavir is a novel anti-influenza therapeutic agent, identifying and characterizing substitutions associated with reduced sensitivity to baloxavir, as well as the impact of these substitutions on viral fitness, is paramount to the strategic implementation of this novel countermeasure.
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Affiliation(s)
- Brady T. Hickerson
- Division of Biotechnology Review and Research II, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Simone E. Adams
- Division of Biotechnology Review and Research II, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Subrata Barman
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Lance Miller
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Vladimir Y. Lugovtsev
- Division of Viral Products, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard J. Webby
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - William L. Ince
- Division of Antiviral Products, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Raymond P. Donnelly
- Division of Biotechnology Review and Research II, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Natalia A. Ilyushina
- Division of Biotechnology Review and Research II, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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19
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Govorkova EA, Takashita E, Daniels RS, Fujisaki S, Presser LD, Patel MC, Huang W, Lackenby A, Nguyen HT, Pereyaslov D, Rattigan A, Brown SK, Samaan M, Subbarao K, Wong S, Wang D, Webby RJ, Yen HL, Zhang W, Meijer A, Gubareva LV. Global update on the susceptibilities of human influenza viruses to neuraminidase inhibitors and the cap-dependent endonuclease inhibitor baloxavir, 2018–2020. Antiviral Res 2022; 200:105281. [PMID: 35292289 PMCID: PMC9254721 DOI: 10.1016/j.antiviral.2022.105281] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 12/19/2022]
Abstract
Global analysis of the susceptibility of influenza viruses to neuraminidase (NA) inhibitors (NAIs) and the polymerase acidic (PA) inhibitor (PAI) baloxavir was conducted by five World Health Organization Collaborating Centres for Reference and Research on Influenza during two periods (May 2018–May 2019 and May 2019–May 2020). Combined phenotypic and NA sequence-based analysis revealed that the global frequency of viruses displaying reduced or highly reduced inhibition (RI or HRI) or potential to show RI/HRI by NAIs remained low, 0.5% (165/35045) and 0.6% (159/26010) for the 2018–2019 and 2019–2020 periods, respectively. The most common amino acid substitution was NA-H275Y (N1 numbering) conferring HRI by oseltamivir and peramivir in A(H1N1)pdm09 viruses. Combined phenotypic and PA sequence-based analysis showed that the global frequency of viruses showing reduced susceptibility to baloxavir or carrying substitutions associated with reduced susceptibility was low, 0.5% (72/15906) and 0.1% (18/15692) for the 2018–2019 and 2019–2020 periods, respectively. Most (n = 61) of these viruses had I38→T/F/M/S/L/V PA amino acid substitutions. In Japan, where baloxavir use was highest, the rate was 4.5% (41/919) in the 2018–2019 period and most of the viruses (n = 32) had PA-I38T. Zoonotic viruses isolated from humans (n = 32) in different countries did not contain substitutions in NA associated with NAI RI/HRI phenotypes. One A(H5N6) virus had a dual substitution PA-I38V + PA-E199G, which may reduce susceptibility to baloxavir. Therefore, NAIs and baloxavir remain appropriate choices for the treatment of influenza virus infections, but close monitoring of antiviral susceptibility is warranted.
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Affiliation(s)
- Elena A Govorkova
- WHO Collaborating Centre for Studies on the Ecology of Influenza in Animals and Birds, St. Jude Children's Research Hospital, Memphis, TN, 38105-3678, USA.
| | - Emi Takashita
- WHO Collaborating Centre for Reference and Research on Influenza, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashimurayama, Tokyo, 208-0011, Japan
| | - Rod S Daniels
- WHO Collaborating Centre for Reference and Research on Influenza, The Francis Crick Institute, Worldwide Influenza Centre, 1 Midland Road, London, NW1 1AT, United Kingdom
| | - Seiichiro Fujisaki
- WHO Collaborating Centre for Reference and Research on Influenza, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashimurayama, Tokyo, 208-0011, Japan
| | - Lance D Presser
- National Institute for Public Health and the Environment, PO Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Mira C Patel
- WHO Collaborating Centre for Surveillance, Epidemiology and Control of Influenza, Centres for Disease Control and Prevention, 1600 Clifton RD NE, MS H17-5, Atlanta, GA, 30329, USA
| | - Weijuan Huang
- WHO Collaborating Centre for Reference and Research on Influenza, National Institute for Viral Disease Control and Prevention, China CDC, Beijing, China
| | - Angie Lackenby
- National Infection Service, Public Health England, London, NW9 5HT, United Kingdom
| | - Ha T Nguyen
- WHO Collaborating Centre for Surveillance, Epidemiology and Control of Influenza, Centres for Disease Control and Prevention, 1600 Clifton RD NE, MS H17-5, Atlanta, GA, 30329, USA
| | - Dmitriy Pereyaslov
- Global Influenza Programme, World Health Organization, Avenue Appia 20, 1211, Geneva, 27, Switzerland
| | - Aine Rattigan
- WHO Collaborating Centre for Reference and Research on Influenza, The Francis Crick Institute, Worldwide Influenza Centre, 1 Midland Road, London, NW1 1AT, United Kingdom
| | - Sook Kwan Brown
- WHO Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, 3000, Australia
| | - Magdi Samaan
- Global Influenza Programme, World Health Organization, Avenue Appia 20, 1211, Geneva, 27, Switzerland
| | - Kanta Subbarao
- WHO Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, 3000, Australia
| | - Sun Wong
- Public Health Laboratory Centre, 382 Nam Cheong Street, Hong Kong, China
| | - Dayan Wang
- WHO Collaborating Centre for Reference and Research on Influenza, National Institute for Viral Disease Control and Prevention, China CDC, Beijing, China
| | - Richard J Webby
- WHO Collaborating Centre for Studies on the Ecology of Influenza in Animals and Birds, St. Jude Children's Research Hospital, Memphis, TN, 38105-3678, USA
| | - Hui-Ling Yen
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wenqing Zhang
- Global Influenza Programme, World Health Organization, Avenue Appia 20, 1211, Geneva, 27, Switzerland
| | - Adam Meijer
- National Institute for Public Health and the Environment, PO Box 1, 3720, BA, Bilthoven, the Netherlands
| | - Larisa V Gubareva
- WHO Collaborating Centre for Surveillance, Epidemiology and Control of Influenza, Centres for Disease Control and Prevention, 1600 Clifton RD NE, MS H17-5, Atlanta, GA, 30329, USA
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20
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Rogolino D, Naesens L, Bartoli J, Carcelli M, De Luca L, Pelosi G, Stokes RW, Van Berwaer R, Vittorio S, Stevaert A, Cohen SM. Exploration of the 2,3-dihydroisoindole pharmacophore for inhibition of the influenza virus PA endonuclease. Bioorg Chem 2021; 116:105388. [PMID: 34670331 DOI: 10.1016/j.bioorg.2021.105388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/09/2021] [Accepted: 09/25/2021] [Indexed: 11/19/2022]
Abstract
Seasonal influenza A and B viruses represent a global concern. Antiviral drugs are crucial to treat severe influenza in high-risk patients and prevent virus spread in case of a pandemic. The emergence of viruses showing drug resistance, in particular for the recently licensed polymerase inhibitor baloxavir marboxil, drives the need for developing alternative antivirals. The endonuclease activity residing in the N-terminal domain of the polymerase acidic protein (PAN) is crucial for viral RNA synthesis and a validated target for drug design. Its function can be impaired by molecules bearing a metal-binding pharmacophore (MBP) able to coordinate the two divalent metal ions in the active site. In the present work, the 2,3-dihydro-6,7-dihydroxy-1H-isoindol-1-one scaffold is explored for the inhibition of influenza virus PA endonuclease. The structure-activity relationship was analysed by modifying the substituents on the lipophilic moiety linked to the MBP. The new compounds exhibited nanomolar inhibitory activity in a FRET-based enzymatic assay, and a few compounds (15-17, 21) offered inhibition in the micromolar range, in a cell-based influenza virus polymerase assay. When investigated against a panel of PA-mutant forms, compound 17 was shown to retain full activity against the baloxavir-resistant I38T mutant. This was corroborated by docking studies providing insight into the binding mode of this novel class of PA inhibitors.
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Affiliation(s)
- Dominga Rogolino
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, and CIRCMSB (Consorzio Interuniversitario di Ricerca in Chimica dei Metalli nei Sistemi Biologici) Parma Unit, 43124 Parma, Italy.
| | - Lieve Naesens
- Rega Institute for Medical Research, KU Leuven - University of Leuven, B-3000 Leuven, Belgium.
| | - Jennifer Bartoli
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, and CIRCMSB (Consorzio Interuniversitario di Ricerca in Chimica dei Metalli nei Sistemi Biologici) Parma Unit, 43124 Parma, Italy
| | - Mauro Carcelli
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, and CIRCMSB (Consorzio Interuniversitario di Ricerca in Chimica dei Metalli nei Sistemi Biologici) Parma Unit, 43124 Parma, Italy
| | - Laura De Luca
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche e Ambientali, Polo Universitario SS. Annunziata, Università di Messina, Viale Palatucci 13, Messina I-98168, Italy
| | - Giorgio Pelosi
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, and CIRCMSB (Consorzio Interuniversitario di Ricerca in Chimica dei Metalli nei Sistemi Biologici) Parma Unit, 43124 Parma, Italy
| | - Ryjul W Stokes
- Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA 92093, United States
| | - Ria Van Berwaer
- Rega Institute for Medical Research, KU Leuven - University of Leuven, B-3000 Leuven, Belgium
| | - Serena Vittorio
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche e Ambientali, Polo Universitario SS. Annunziata, Università di Messina, Viale Palatucci 13, Messina I-98168, Italy
| | - Annelies Stevaert
- Rega Institute for Medical Research, KU Leuven - University of Leuven, B-3000 Leuven, Belgium
| | - Seth M Cohen
- Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA 92093, United States
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21
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Baloxavir Treatment Delays Influenza B Virus Transmission in Ferrets and Results in Limited Generation of Drug-Resistant Variants. Antimicrob Agents Chemother 2021; 65:e0113721. [PMID: 34424039 DOI: 10.1128/aac.01137-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Clinical efficacy of the influenza antiviral baloxavir marboxil (baloxavir) is compromised by treatment-emergent variants harboring a polymerase acidic protein I38T (isoleucine-38-threonine) substitution. However, the fitness of I38T-containing influenza B viruses (IBVs) remains inadequately defined. After the pharmacokinetics of the compound were confirmed in ferrets, animals were injected subcutaneously with 8 mg/kg of baloxavir acid (BXA) at 24 h postinoculation with recombinant BXA-sensitive (BXA-Sen, I38) or BXA-resistant (BXA-Res, I38T) B/Brisbane/60/2008 (Victoria lineage) virus. BXA treatment of donor ferrets reduced virus replication and delayed transmission of the BXA-Sen but not the BXA-Res IBV. The I38 genotype remained dominant in the BXA-Sen-infected animals, even with BXA treatment. In competitive-mixture experiments, no transmission to aerosol contacts was seen from BXA-treated donors coinfected with the BXA-Sen and BXA-Res B/Brisbane/60/2008 viruses. However, in parallel mixed infections with the B/Phuket/3073/2013 (Yamagata lineage) virus background, BXA treatment failed to block airborne transmission of the BXA-Res virus, and the I38T genotype generally predominated. Therefore, the relative fitness of BXA-Res IBVs is complex and dependent on the virus backbone and within-host virus competition. BXA treatment of single-virus-infected ferrets hampers aerosol transmission of the BXA-Sen virus and does not readily generate BXA-Res variants, whereas mixed infections may result in propagation of BXA-Res IBVs of the Yamagata lineage. Our findings confirm the antiviral potency of baloxavir against IBVs, while supporting optimization of the dosing regimen to maximize clinical benefit.
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Abstract
This technical report accompanies the recommendations of the American Academy of Pediatrics for the routine use of the influenza vaccine and antiviral medications in the prevention and treatment of influenza in children during the 2021-2022 season. Influenza vaccination is an important intervention to protect vulnerable populations and reduce the burden of respiratory illnesses during circulation of severe acute respiratory syndrome coronavirus 2, which is expected to continue during this influenza season. In this technical report, we summarize recent influenza seasons, morbidity and mortality in children, vaccine effectiveness, vaccination coverage, and detailed guidance on storage, administration, and implementation. We also provide background on inactivated and live attenuated influenza vaccine recommendations, vaccination during pregnancy and breastfeeding, diagnostic testing, and antiviral medications for treatment and chemoprophylaxis.
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MESH Headings
- Antiviral Agents/therapeutic use
- Breast Feeding
- Child
- Contraindications, Drug
- Drug Resistance, Viral
- Drug Storage
- Female
- Hospitalization
- Humans
- Influenza Vaccines/administration & dosage
- Influenza Vaccines/adverse effects
- Influenza, Human/drug therapy
- Influenza, Human/epidemiology
- Influenza, Human/mortality
- Influenza, Human/prevention & control
- Mass Vaccination
- Risk Factors
- United States/epidemiology
- Vaccines, Attenuated/administration & dosage
- Vaccines, Attenuated/adverse effects
- Vaccines, Inactivated/administration & dosage
- Vaccines, Inactivated/adverse effects
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Ison MG, Hayden FG, Hay AJ, Gubareva LV, Govorkova EA, Takashita E, McKimm-Breschkin JL. Influenza polymerase inhibitor resistance: Assessment of the current state of the art - A report of the isirv Antiviral group. Antiviral Res 2021; 194:105158. [PMID: 34363859 PMCID: PMC9012257 DOI: 10.1016/j.antiviral.2021.105158] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 12/31/2022]
Abstract
It is more than 20 years since the neuraminidase inhibitors, oseltamivir and zanamivir were approved for the treatment and prevention of influenza. Guidelines for global surveillance and methods for evaluating resistance were established initially by the Neuraminidase Inhibitor Susceptibility Network (NISN), which merged 10 years ago with the International Society for influenza and other Respiratory Virus Diseases (isirv) to become the isirv-Antiviral Group (isirv-AVG). With the ongoing development of new influenza polymerase inhibitors and recent approval of baloxavir marboxil, the isirv-AVG held a closed meeting in August 2019 to discuss the impact of resistance to these inhibitors. Following this meeting and review of the current literature, this article is intended to summarize current knowledge regarding the clinical impact of resistance to polymerase inhibitors and approaches for surveillance and methods for laboratory evaluation of resistance, both in vitro and in animal models. We highlight limitations and gaps in current knowledge and suggest some strategies for addressing these gaps, including the need for additional clinical studies of influenza antiviral drug combinations. Lessons learned from influenza resistance monitoring may also be helpful for establishing future drug susceptibility surveillance and testing for SARS-CoV-2.
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Affiliation(s)
- Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Alan J Hay
- The Francis Crick Institute, London, UK.
| | - Larisa V Gubareva
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Elena A Govorkova
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Emi Takashita
- National Institute of Infectious Diseases, Tokyo, Japan.
| | - Jennifer L McKimm-Breschkin
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Victoria, Australia.
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24
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Whole-Genome Analysis Surveillance of Influenza A Virus Resistance to Polymerase Complex Inhibitors in Eastern Spain from 2016 to 2019. Antimicrob Agents Chemother 2021; 65:AAC.02718-20. [PMID: 33782005 DOI: 10.1128/aac.02718-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/22/2021] [Indexed: 02/06/2023] Open
Abstract
Molecular surveillance by whole-genome sequencing was used to monitor the susceptibility of circulating influenza A viruses to three polymerase complex inhibitors. A total of 12 resistance substitutions were found among 285 genomes analyzed, but none were associated with high levels of resistance. Natural resistance to these influenza A antivirals is currently uncommon.
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Kuo YC, Lai CC, Wang YH, Chen CH, Wang CY. Clinical efficacy and safety of baloxavir marboxil in the treatment of influenza: A systematic review and meta-analysis of randomized controlled trials. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:865-875. [PMID: 34020891 DOI: 10.1016/j.jmii.2021.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/03/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of this meta-analysis is to compare the clinical efficacy and safety of baloxavir with other anti-influenza agents or placebo in the treatment of influenza. METHODS PubMed, Embase, Web of Science, Google Scholar, Scopus, CINAHL, Cochrane databases and clinical registration were searched from inception until February 15 2021 for relevant randomized controlled trials (RCTs). Only phase 3 RCTs evaluating the usefulness of baloxavir in the treatment of influenza were included. RESULTS Three RCTs enrolling 3771 patients (baloxavir group, n = 1451; oseltamivir group, n = 1288; placebo group, n = 1032) were included. Compared with oseltamivir, baloxavir had an insignificantly shorter time to the alleviation of symptoms (mean difference [MD], -1.29 h; 95% CI, -6.80 to 4.21; I2 = 0%). In contrast, baloxavir had a significantly shorter time to the alleviation of symptoms than placebo (MD, -26.32 h; 95% CI, -33.78 to -18.86; I2 = 0%). Baloxavir was associated with a significant decline in influenza virus titers and viral RNA load compared to oseltamivir and placebo. Baloxavir was associated with a lower risk of any adverse events than oseltamivir (OR, 0.82; 95% CI, 0.69-0.98; I2 = 0%) and placebo (OR, 0.79; 95% CI, 0.66-0.96; I2 = 0%). CONCLUSIONS The findings of this meta-analysis suggested that baloxavir is superior to placebo in the treatment of influenza in both clinical outcome and virological response. Moreover, baloxavir was found to have a better virological response than oseltamivir and to be as effective as oseltamivir clinically. Compared with oseltamivir and placebo, baloxavir appears to be a relatively safe anti-influenza agent.
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Affiliation(s)
- Yu-Chi Kuo
- Department of Internal Medicine, Chi-Mei Hospital, Chiali, Tainan, Taiwan.
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan, Taiwan.
| | - Ya-Hui Wang
- Medical Research Center, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan.
| | - Chao-Hsien Chen
- Division of Pulmonary, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, New Taipei, Taiwan.
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan.
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Development of cycling probe based real-time PCR methodology for influenza A viruses possessing the PA/I38T amino acid substitution associated with reduced baloxavir susceptibility. Antiviral Res 2021; 188:105036. [PMID: 33577807 DOI: 10.1016/j.antiviral.2021.105036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
Baloxavir marboxil has been used for influenza treatment since March 2018 in Japan. After baloxavir treatment, the most frequently detected substitution is Ile38Thr in polymerase acidic protein (PA/I38T), and this substitution reduces baloxavir susceptibility in influenza A viruses. To rapidly investigate the frequency of PA/I38T in influenza A (H1N1)pdm09 and A (H3N2) viruses in clinical samples, we established a rapid real-time system to detect single nucleotide polymorphisms in PA, using cycling probe real-time PCR. We designed two sets of probes that were labeled with either 6-carboxyfluorescein (FAM) or 6-carboxy-X-rhodamine (ROX) to identify PA/I38 (wild type strain) or PA/I38T, respectively. The established cycling probe real-time PCR system showed a dynamic linear range of 101 to 106 copies with high sensitivity in plasmid DNA controls. This real-time PCR system discriminated between PA/I38T and wild type viruses well. During the 2018/19 season, 377 influenza A-positive clinical samples were collected in Japan before antiviral treatment. Using our cycling probe real-time PCR system, we detected no (0/129, 0.0%) influenza A (H1N1)pdm09 viruses with PA/I38T substitutions and four A (H3N2) (4/229, 1.7%) with PA/I38T substitution prior to treatment. In addition, we found PA/I38T variant in siblings who did not received baloxavir treatment during an infection caused by A (H3N2) that afflicted the entire family. Although human-to-human transmission of PA/I38T variant may have occurred in a closed environment, the prevalence of this variant in influenza A viruses was still limited. Our cycling probe-PCR system is thus useful for antiviral surveillance of influenza A viruses possessing PA/I38T.
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Newman KL, Rogers JH, McCulloch D, Wilcox N, Englund JA, Boeckh M, Uyeki TM, Jackson ML, Starita L, Hughes JP, Chu HY. Point-of-care molecular testing and antiviral treatment of influenza in residents of homeless shelters in Seattle, WA: study protocol for a stepped-wedge cluster-randomized controlled trial. Trials 2020; 21:956. [PMID: 33228787 PMCID: PMC7682130 DOI: 10.1186/s13063-020-04871-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 11/04/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Influenza is an important public health problem, but data on the impact of influenza among homeless shelter residents are limited. The primary aim of this study is to evaluate whether on-site testing and antiviral treatment of influenza in residents of homeless shelters reduces influenza spread in these settings. Methods and analysis This study is a stepped-wedge cluster-randomized trial of on-site testing and antiviral treatment for influenza in nine homeless shelter sites within the Seattle metropolitan area. Participants with acute respiratory illness (ARI), defined as two or more respiratory symptoms or new or worsening cough with onset in the prior 7 days, are eligible to enroll. Approximately 3200 individuals are estimated to participate from October to May across two influenza seasons. All sites will start enrollment in the control arm at the beginning of each season, with routine surveillance for ARI. Sites will be randomized at different timepoints to enter the intervention arm, with implementation of a test-and-treat strategy for individuals with two or fewer days of symptoms. Eligible individuals will be tested on-site with a point-of-care influenza test. If the influenza test is positive and symptom onset is within 48 h, participants will be administered antiviral treatment with baloxavir or oseltamivir depending upon age and comorbidities. Participants will complete a questionnaire on demographics and symptom duration and severity. The primary endpoint is the incidence of influenza in the intervention period compared to the control period, after adjusting for time trends. Trial registration ClinicalTrials.gov NCT04141917. Registered 28 October 2019. Trial sponsor: University of Washington. Supplementary information The online version contains supplementary material available at 10.1186/s13063-020-04871-5.
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Affiliation(s)
- Kira L Newman
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA
| | - Julia H Rogers
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA
| | - Denise McCulloch
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA
| | - Naomi Wilcox
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA
| | - Janet A Englund
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA.,Seattle Children's Research Institute, Seattle, WA, USA
| | - Michael Boeckh
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Timothy M Uyeki
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Lea Starita
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA
| | - James P Hughes
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA
| | - Helen Y Chu
- Division of Allergy and Infectious Diseases, University of Washington, UW Medicine at South Lake Union, Chu Lab Room E630, 750 Republican St., Seattle, WA, 98109, USA.
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Saito R, Osada H, Wagatsuma K, Chon I, Sato I, Kawashima T, Saito T, Kodo N, Ono Y, Shimada Y, Phyu W, Shobugawa Y. Duration of fever and symptoms in children after treatment with baloxavir marboxil and oseltamivir during the 2018–2019 season and detection of variant influenza a viruses with polymerase acidic subunit substitutions. Antiviral Res 2020; 183:104951. [DOI: 10.1016/j.antiviral.2020.104951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
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29
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Hashimoto T, Baba K, Inoue K, Okane M, Hata S, Shishido T, Naito A, Wildum S, Omoto S. Comprehensive assessment of amino acid substitutions in the trimeric RNA polymerase complex of influenza A virus detected in clinical trials of baloxavir marboxil. Influenza Other Respir Viruses 2020; 15:389-395. [PMID: 33099886 PMCID: PMC8051730 DOI: 10.1111/irv.12821] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 01/18/2023] Open
Abstract
Background Baloxavir marboxil (BXM) is an approved drug that selectively targets cap‐dependent endonuclease on PA subunit in the RNA polymerase complex of influenza A and B viruses. Amino acid substitutions at position 38 in the PA subunit were identified as a major pathway for reduced susceptibility to baloxavir acid (BXA), the active form of BXM. Additionally, substitutions found at positions E23, A37, and E199 in the PA subunit impact BXA susceptibility by less than 10‐fold. Methods We comprehensively evaluated the impact of novel amino acid substitutions identified in PA, PB1, and PB2 subunits in BXM clinical trials and influenza sequence databases by means of drug susceptibility and replicative capacity. Results PA/I38N in A(H1N1)pdm09 and PA/I38R in A(H3N2) were newly identified as treatment‐emergent substitutions in the CAPSTONE‐2 study. The I38N substitution conferred reduced susceptibility by 24‐fold, whereas replicative capacity of the I38N‐substituted virus was impaired compared with the wild‐type. The I38R‐substituted virus was not viable in cell culture. All other mutations assessed in this extensive study did not significantly affect BXA susceptibility (< 2.4‐fold change). Conclusion These results provide additional information on the impact of amino acid substitutions in the trimeric viral polymerase complex to BXA susceptibility and will further support influenza surveillance.
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Affiliation(s)
- Takashi Hashimoto
- Shionogi & Co., Ltd., Osaka, Japan.,Shionogi Techno Advance Research, Co., Ltd., Osaka, Japan
| | | | - Kae Inoue
- Shionogi Techno Advance Research, Co., Ltd., Osaka, Japan
| | - Miyako Okane
- Shionogi Techno Advance Research, Co., Ltd., Osaka, Japan
| | - Satoshi Hata
- Shionogi Techno Advance Research, Co., Ltd., Osaka, Japan
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Patel MC, Mishin VP, De La Cruz JA, Chesnokov A, Nguyen HT, Wilson MM, Barnes J, Kondor RJG, Wentworth DE, Gubareva LV. Detection of baloxavir resistant influenza A viruses using next generation sequencing and pyrosequencing methods. Antiviral Res 2020; 182:104906. [PMID: 32798601 PMCID: PMC7426223 DOI: 10.1016/j.antiviral.2020.104906] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 11/11/2022]
Abstract
Baloxavir, a new antiviral drug targeting cap-dependent endonuclease activity of polymerase acidic (PA) protein of influenza viruses, is now approved in multiple countries. Several substitutions at isoleucine 38 in PA protein (e.g., PA-I38T) have been associated with decreased baloxavir susceptibility in vitro and in vivo. In recent years, next generation sequencing (NGS) analysis and pyrosequencing have been used by CDC and U.S. Public Health Laboratories to monitor drug susceptibility of influenza viruses. Here we described an improved pyrosequencing assay for detecting influenza A viruses carrying substitutions at PA-38. Cyclic and customized orders of nucleotide dispensation were evaluated, and pyrosequencing results were compared to those generated using NGS. Our data showed that the customized nucleotide dispensation has improved the pyrosequencing assay performance in identification of double mixtures (e.g., PA-38I/T); however, identification of PA-38 variants in triple mixtures remains a challenge. While NGS analysis indicated the presence of PA-I38K in one clinical specimen and isolate, our attempts to detect this mutation by pyrosequencing or recover the virus carrying PA-I38K in cell culture were unsuccessful, raising a possibility of a rarely occurring sequencing error. Overall, pyrosequencing provides a convenient means to detect baloxavir resistant influenza viruses when NGS is unavailable or a faster turnaround time is required. Pyrosequencing assay was optimized to improve detection of baloxavir resistant influenza A viruses in mixtures. Detection of PA-38 variants in virus mixtures of both subtypes was improved by using customized nucleotide dispensation. Pyrosequencing and NGS data were comparable, except for lysine at PA-38 that was detected by NGS but not by pyrosequencing. Attempts to recover virus carrying lysine at PA-38 were unsuccessful, raising the rare possibility of an NGS artifact. Pyrosequencing provides an important addition to genotypic methods that can be used for baloxavir susceptibility testing.
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Affiliation(s)
- Mira C Patel
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - Vasiliy P Mishin
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - Juan A De La Cruz
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA; Battelle Memorial Institute, Atlanta, GA, USA
| | - Anton Chesnokov
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - Ha T Nguyen
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA; Battelle Memorial Institute, Atlanta, GA, USA
| | - Malania M Wilson
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - John Barnes
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - Rebecca J G Kondor
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - David E Wentworth
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA
| | - Larisa V Gubareva
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers of Disease Control and Prevention, Atlanta, GA, USA.
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Fujita J. Clinical application of baloxavir marboxil in the treatment of influenza. Respir Investig 2020; 58:301-304. [PMID: 32669226 DOI: 10.1016/j.resinv.2020.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/11/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Jiro Fujita
- Department of Infectious, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan.
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Abed Y, Fage C, Checkmahomed L, Venable MC, Boivin G. Characterization of contemporary influenza B recombinant viruses harboring mutations of reduced susceptibility to baloxavir marboxil, in vitro and in mice. Antiviral Res 2020; 179:104807. [DOI: 10.1016/j.antiviral.2020.104807] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 10/24/2022]
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