Proved viraemia in Asian influenza (Hong Kong variant) during incubation period

Prevalence and clinical relevance of viraemia in viral respiratory tract infections: a systematic review

In this Review, we analysed the prevalence of viraemia during infection with SARS-CoV-2 and other relevant respiratory viruses, including other human coronaviruses such as MERS-CoV and SARS-CoV, adenovirus, human metapneumovirus, human rhinovirus/enterovirus, influenza A and B virus, parainfluenza virus, and respiratory syncytial virus. First, a preliminary systematic search was conducted to identify articles published before May 23, 2024 that reported on viraemia during infection with respiratory viruses. The articles were then analysed for relevant terms to identify the prevalence of viraemia, its association with the disease severity and long-term consequences, and host responses. A total of 202 articles were included in the final study. The pooled prevalence of viraemia was 34% for SARS-CoV-2 and between 6% and 65% for other viruses. Association of viraemia with disease severity was extensively reported for SARS-CoV-2 and also for SARS-CoV, MERS-CoV, adenoviruses, rhinoviruses, respiratory syncytial virus, and influenza A(H1N1)pdm09 (albeit with low evidence). SARS-CoV-2 viraemia was linked to memory problems and worsened quality of life. Viraemia was associated with signatures denoting dysregulated host responses. In conclusion, the high prevalence of viraemia and its association with disease severity suggests that viraemia could be a relevant pathophysiological event with important translational implications in respiratory viral infections.

Passive immunotherapies for the next influenza pandemic

Influenzavirus is among the most relevant candidates for a next pandemic. We review here the phylogeny of former influenza pandemics, and discuss candidate lineages. After briefly reviewing the other existing antiviral options, we discuss in detail the evidences supporting the efficacy of passive immunotherapies against influenzavirus, with a focus on convalescent plasma.

Influenza A virus replicates productively in primary human kidney cells and induces factors and mechanisms related to regulated cell death and renal pathology observed in virus-infected patients

Introduction

Influenza A virus (IAV) infection can cause the often-lethal acute respiratory distress syndrome (ARDS) of the lung. Concomitantly, acute kidney injury (AKI) is frequently noticed during IAV infection, correlating with an increased mortality. The aim of this study was to elucidate the interaction of IAV with human kidney cells and, thereby, to assess the mechanisms underlying IAV-mediated AKI.

Methods

To investigate IAV effects on nephron cells we performed infectivity assays with human IAV, as well as with human isolates of either low or highly pathogenic avian IAV. Also, transcriptome and proteome analysis of IAV-infected primary human distal tubular kidney cells (DTC) was performed. Furthermore, the DTC transcriptome was compared to existing transcriptomic data from IAV-infected lung and trachea cells.

Results

We demonstrate productive replication of all tested IAV strains on primary and immortalized nephron cells. Comparison of our transcriptome and proteome analysis of H1N1-type IAV-infected human primary distal tubular cells (DTC) with existing data from H1N1-type IAV-infected lung and primary trachea cells revealed enrichment of specific factors responsible for regulated cell death in primary DTC, which could be targeted by specific inhibitors.

Discussion

IAV not only infects, but also productively replicates on different human nephron cells. Importantly, multi-omics analysis revealed regulated cell death as potential contributing factor for the clinically observed kidney pathology in influenza.

Maternal Influenza and Offspring Neurodevelopment

This review examines the complex interactions between maternal influenza infection, the immune system, and the neurodevelopment of the offspring. It highlights the importance of high-quality studies to clarify the association between maternal exposure to the virus and neuropsychiatric disorders in the offspring. Additionally, it emphasizes that the development of accurate animal models is vital for studying the impact of infectious diseases during pregnancy and identifying potential therapeutic targets. By drawing attention to the complex nature of these interactions, this review underscores the need for ongoing research to improve the understanding and outcomes for pregnant women and their offspring.

RNAemia Corresponds to Disease Severity and Antibody Response in Hospitalized COVID-19 Patients

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) represents a global health emergency. To improve the understanding of the systemic component of SARS-CoV-2, we investigated if viral load dynamics in plasma and respiratory samples are associated with antibody response and severity of coronavirus disease 2019 (COVID-19). SARS-CoV-2 RNA was found in plasma samples from 14 (44%) out of 32 patients. RNAemia was detected in 5 out of 6 fatal cases. Peak IgG values were significantly lower in mild/moderate than in severe (0.6 (interquartile range, IQR, 0.4–3.2) vs. 11.8 (IQR, 9.9–13.0), adjusted p = 0.003) or critical cases (11.29 (IQR, 8.3–12.0), adjusted p = 0.042). IgG titers were significantly associated with virus Ct (Cycle threshold) value in plasma and respiratory specimens ((ß = 0.4, 95% CI (confidence interval, 0.2; 0.5), p < 0.001 and ß = 0.5, 95% CI (0.2; 0.6), p = 0.002). A classification as severe or a critical case was additionally inversely associated with Ct values in plasma in comparison to mild/moderate cases (ß = −3.3, 95% CI (−5.8; 0.8), p = 0.024 and ß = −4.4, 95% CI (−7.2; 1.6), p = 0.007, respectively). Based on the present data, our hypothesis is that the early stage of SARS-CoV-2 infection is characterized by a primary RNAemia, as a potential manifestation of a systemic infection. Additionally, the viral load in plasma seems to be associated with a worse disease outcome.

Seasonality and selective trends in viral acute respiratory tract infections

Influenza A and B, and many unrelated viruses including rhinovirus, RSV, adenovirus, metapneumovirus and coronavirus share the same seasonality, since these viral acute respiratory tract infections (vARIs) are much more common in winter than summer. Unfortunately, early investigations that used recycled “pedigree” virus strains seem to have led microbiologists to dismiss the common folk belief that vARIs often follow chilling. Today, incontrovertible evidence shows that ambient temperature dips and host chilling increase the incidence and severity of vARIs. This review considers four possible mechanisms, M1 - 4, that can explain this link: (M1) increased crowding in winter may enhance viral transmission; (M2) lower temperatures may increase the stability of virions outside the body; (M3) chilling may increase host susceptibility; (M4) lower temperatures or host chilling may activate dormant virions. There is little evidence for M1 or M2, which are incompatible with tropical observations. Epidemiological anomalies such as the repeated simultaneous arrival of vARIs over wide geographical areas, the rapid cessation of influenza epidemics, and the low attack rate of influenza within families are compatible with M4, but not M3 (in its simple form). M4 seems to be the main driver of seasonality, but M3 may also play an important role.

Influenza, immune system, and pregnancy

Influenza is a major health problem worldwide. Both seasonal influenza and pandemics take a major toll on the health and economy of our country. The present review focuses on the virology and complex immunology of this RNA virus in general and in relation to pregnancy. The goal is to attempt to explain the increased morbidity and mortality seen in infection during pregnancy. We discuss elements of innate and adaptive immunity as well as placental cellular responses to infection. In addition, we delineate findings in animal models as well as human disease. Increased knowledge of maternal and fetal immunologic responses to influenza is needed. However, enhanced understanding of nonimmune, pregnancy-specific factors influencing direct interaction of the virus with host cells is also important for the development of more effective prevention and treatment options in the future.

Neurologic aspects of influenza viruses

Although influenza A and B viruses are primarily known as respiratory viruses and mainly infected only the upper respiratory tract in humans, patients with influenza often develop signs and symptoms that are not due to the respiratory system. Frequently individuals with influenza develop headaches, meningismus, and even seizures in addition to their typical respiratory symptoms. In the past decades, influenza viruses have also been associated with serious non-respiratory signs. The famous 1918 strain of influenza was associated with von Economo's encephalitis lethargica and postencephalitic parkinsonism. In the 1960s influenza virus infections in children were associated with Reye's syndrome characterized often by fatty non-inflammatory hepatic disease and an encephalopathy with marked non-inflammatory cerebral edema. Intermittently children with influenza develop focal myalgia and myositis. Guillain–Barré syndrome was epidemiologically associated with the 1978 killed influenza vaccine but not subsequent vaccines. Although occasional children with influenza have developed encephalopathy, from 2000 through 2004 there was an increase in the number of serious cases of acute necrotizing encephalopathy accompanying infection with the influenza A 2009 strain. The current H5N1 strain of bird influenza occasionally infects humans with a high mortality rate and some appear to have central nervous signs. This chapter explores what is known about these influenza neurologic associations.

Comparison of shedding characteristics of seasonal influenza virus (sub)types and influenza A(H1N1)pdm09; Germany, 2007-2011

Background

Influenza viral shedding studies provide fundamental information for preventive strategies and modelling exercises. We conducted a prospective household study to investigate viral shedding in seasonal and pandemic influenza between 2007 and 2011 in Berlin and Munich, Germany.

Methods

Study physicians recruited index patients and their household members. Serial nasal specimens were obtained from all household members over at least eight days and tested quantitatively by qRT-PCR for the influenza virus (sub)type of the index patient. A subset of samples was also tested by viral culture. Symptoms were recorded daily.

Results

We recruited 122 index patients and 320 household contacts, of which 67 became secondary household cases. Among all 189 influenza cases, 12 were infected with seasonal/prepandemic influenza A(H1N1), 19 with A(H3N2), 60 with influenza B, and 98 with A(H1N1)pdm09. Nine (14%) of 65 non-vaccinated secondary cases were asymptomatic/subclinical (0 (0%) of 21 children, 9 (21%) of 44 adults; p = 0.03). Viral load among patients with influenza-like illness (ILI) peaked on illness days 1, 2 or 3 for all (sub)types and declined steadily until days 7–9. Clinical symptom scores roughly paralleled viral shedding dynamics. On the first day prior to symptom onset 30% (12/40) of specimens were positive. Viral load in 6 asymptomatic/subclinical patients was similar to that in ILI-patients. Duration of infectiousness as measured by viral culture lasted approximately until illness days 4–6. Viral load did not seem to be influenced by antiviral therapy, age or vaccination status.

Conclusion

Asymptomatic/subclinical infections occur infrequently, but may be associated with substantial amounts of viral shedding. Presymptomatic shedding may arise in one third of cases, and shedding characteristics appear to be independent of (seasonal or pandemic) (sub)type, age, antiviral therapy or vaccination; however the power to find moderate differences was limited.

A novel pathogenic mechanism of highly pathogenic avian influenza H5N1 viruses involves hemagglutinin mediated resistance to serum innate inhibitors

In this study, the effect of innate serum inhibitors on influenza virus infection was addressed. Seasonal influenza A(H1N1) and A(H3N2), 2009 pandemic A(H1N1) (H1N1pdm) and highly pathogenic avian influenza (HPAI) A(H5N1) viruses were tested with guinea pig sera negative for antibodies against all of these viruses as evaluated by hemagglutination-inhibition and microneutralization assays. In the presence of serum inhibitors, the infection by each virus was inhibited differently as measured by the amount of viral nucleoprotein produced in Madin-Darby canine kidney cells. The serum inhibitors inhibited seasonal influenza A(H3N2) virus the most, while the effect was less in seasonal influenza A(H1N1) and H1N1pdm viruses. The suppression by serum inhibitors could be reduced by heat inactivation or treatment with receptor destroying enzyme. In contrast, all H5N1 strains tested were resistant to serum inhibitors. To determine which structure (hemagglutinin (HA) and/or neuraminidase (NA)) on the virus particles that provided the resistance, reverse genetics (rg) was applied to construct chimeric recombinant viruses from A/Puerto Rico/8/1934(H1N1) (PR8) plasmid vectors. rgPR8-H5 HA and rgPR8-H5 HANA were resistant to serum inhibitors while rgPR8-H5 NA and PR8 A(H1N1) parental viruses were sensitive, suggesting that HA of HPAI H5N1 viruses bestowed viral resistance to serum inhibition. These results suggested that the ability to resist serum inhibition might enable the viremic H5N1 viruses to disseminate to distal end organs. The present study also analyzed for correlation between susceptibility to serum inhibitors and number of glycosylation sites present on the globular heads of HA and NA. H3N2 viruses, the subtype with highest susceptibility to serum inhibitors, harbored the highest number of glycosylation sites on the HA globular head. However, this positive correlation cannot be drawn for the other influenza subtypes.

George K, Hewlett IK, Linnen JM, Norris PJ. Sensitive detection assays for influenza RNA do not reveal viremia in US blood donors

BACKGROUND

There have been anecdotal reports of influenza viremia since the 1960s. We present an assessment of the prevalence of seasonal and 2009 H1N1 influenza viremia (via RNA testing) in blood donor populations using multiple sensitive detection assays.

METHODS

Several influenza RNA amplification assays, including transcription-mediated amplification (TMA) and 2 reverse-transcription polymerase chain reaction (RT-PCR) assays, were evaluated and used to test donor samples. Retrospective samples from 478 subjects drawn at sites with high influenza activity were tested. Prospective samples were collected from 1004 blood donors who called their donation center within 3 days of donation complaining of influenza-like illness (ILI). The plasma collected on the day of donation for these subjects was tested.

RESULTS

Of the repository samples, 2 of 478 plasma samples were initially reactive but not repeat reactive by influenza TMA. Of blood donors reporting ILI symptoms postdonation, 1 of 1004 samples was TMA initially reactive but not repeat reactive; all samples were nonreactive by RT-PCR testing.

CONCLUSIONS

Targeting blood donor populations most likely to have influenza infection, we failed to detect influenza RNA in 1482 donor samples, with most tested by 3 different RNA assays. Seasonal influenza does not appear to pose a significant contamination threat to the blood supply.

No viremia of pandemic (H1N1) 2009 was demonstrated in blood donors who had donated blood during the probable incubation period

BACKGROUND

In the spring of 2009, the novel swine-origin influenza A (pandemic [H1N1] 2009) virus emerged and spread globally. Although no established cases of transfusion-transmitted influenza have been reported, the widespread outbreak of pandemic (H1N1) 2009 caused serious concern regarding the safety of blood products. The Japanese Red Cross Blood Centers have intercepted blood products with accompanying postdonation information indicating possible pandemic (H1N1) 2009 infection. To study the risk of transmission of pandemic (H1N1) 2009 by blood transfusion, we searched for the viral genome in such products using nucleic acid amplification technology.

STUDY DESIGN AND METHODS

Between June and December 2009, blood components were collected from 579 blood donors who were diagnosed as or strongly suspected of having pandemic (H1N1) 2009 within 7 days after donation. Viral RNA was extracted from plasma and red blood cell (RBC) products, and RNA samples were subjected to real-time reverse transcription-polymerase chain reaction of the hemagglutinin and matrix genes of the pandemic (H1N1) 2009 virus.

RESULTS

A total of 565 plasma and 413 RBC products from the 579 blood donors were available. No viral RNA of the pandemic (H1N1) 2009 was detected in any of the blood samples from the 579 blood donors.

CONCLUSION

No viremia of pandemic (H1N1) 2009 was demonstrated in any of the 579 blood donors who had most likely donated blood during the incubation period. It is considered that the risk of transmitting pandemic (H1N1) 2009 by blood transfusion is extremely low.

[Evaluation of the potential organ and tissue donor within the pandemic of influenza H1N1]

The pandemic strain of H1N1 supposes a challenge to the health care system in general and for Intensive Care Units (ICU) in particular. Therefore, it will undoubtedly have repercussions on the organ and tissue donation process. In a possible scenario of bed shortage in the ICU and difficulties in maintaining the surgical activity at a normal pace, a significant effort must be made to assure the maintenance of normal transplant activity, which should not be considered as an elective surgical procedure. Another problem related with the impact of the pandemic on the organ donation process is the possibility that a donor with influenza virus could transmit the disease to recipients. This work aims to clarify this issue, reviewing existing data on the potential transmission of influenza viruses with transplanted organs or tissue, the recommendations published in other countries and those developed in Spain by an ad hoc work group that is made up by representatives from the National Transplant Organization, the Ministry of Health and Social Policy, Regional Offices of Transplant Coordination, and various scientific societies, including SEMICYUC.

Pathology of human influenza revisited

The pathology of human influenza has been studied most intensively during the three pandemics of the last century, the last of which occurred in 1968. It is important to revisit this subject because of the recent emergence of avian H5N1 influenza in humans as well as the threat of a new pandemic. Uncomplicated human influenza virus infection causes transient tracheo-bronchitis, corresponding with predominant virus attachment to tracheal and bronchial epithelial cells. The main complication is extension of viral infection to the alveoli, often with secondary bacterial infection, resulting in severe pneumonia. Complications in extra-respiratory tissues such as encephalopathy, myocarditis, and myopathy occur occasionally. Sensitive molecular and immunological techniques allow us to investigate whether these complications are a direct result of virus infection or an indirect result of severe pneumonia. Human disease from avian influenza virus infections is most severe for subtype H5N1, but also has been reported for H7 and H9 subtypes. In contrast to human influenza viruses, avian H5N1 virus attaches predominantly to alveolar and bronchiolar epithelium, corresponding with diffuse alveolar damage as the primary lesion. Viremia and extra-respiratory complications appear to be more common for infections with avian H5N1 virus than with human influenza viruses. Further understanding and comparison of the pathology of human and avian influenza virus infections only can be achieved by directed and careful pathological analysis of additional influenza cases.

H5N1 influenza virus and the safety of plasma products

BACKGROUND

The ever-increasing number of human H5N1 influenza virus infections may enable these viruses to acquire the ability to spread effectively among humans and potentially to cause a pandemic. Recently, more systemic virus dissemination was reported during H5N1 virus infection of humans, resulting in significant virus concentrations also in the blood. The observation has raised concerns about the safety of labile blood products for transfusion and consequentially also for plasma derivatives. To confirm the safety margins of plasma products, dedicated virus inactivation processes used during their production were investigated for their effectiveness in inactivating this virus of recent concern.

STUDY DESIGN AND METHODS

Virus inactivation by steps commonly used during the manufacture of plasma derivatives, such as pasteurization for human albumin, solvent/detergent treatment for intravenous immunoglobulin (IVIG), vapor heating for factor VIII inhibitor bypassing activity, and incubation at low pH for IVIG, were investigated with a reassortant strain of H5N1 influenza virus.

RESULTS

The results show that H5N1 influenza behaves as expected for lipid-enveloped viruses; that is, the virus is effectively inactivated by all the commonly used virus inactivation procedures tested.

CONCLUSION

The safety margins of plasma derivatives against the theoretical transmission of H5N1 influenza virus are very substantial.

Comparative estimation of the reproduction number for pandemic influenza from daily case notification data

The reproduction number, R, defined as the average number of secondary cases generated by a primary case, is a crucial quantity for identifying the intensity of interventions required to control an epidemic. Current estimates of the reproduction number for seasonal influenza show wide variation and, in particular, uncertainty bounds for R for the pandemic strain from 1918 to 1919 have been obtained only in a few recent studies and are yet to be fully clarified. Here, we estimate R using daily case notifications during the autumn wave of the influenza pandemic (Spanish flu) in the city of San Francisco, California, from 1918 to 1919. In order to elucidate the effects from adopting different estimation approaches, four different methods are used: estimation of R using the early exponential-growth rate (Method 1), a simple susceptible-exposed-infectious-recovered (SEIR) model (Method 2), a more complex SEIR-type model that accounts for asymptomatic and hospitalized cases (Method 3), and a stochastic susceptible-infectious-removed (SIR) with Bayesian estimation (Method 4) that determines the effective reproduction number Rt at a given time t. The first three methods fit the initial exponential-growth phase of the epidemic, which was explicitly determined by the goodness-of-fit test. Moreover, Method 3 was also fitted to the whole epidemic curve. Whereas the values of R obtained using the first three methods based on the initial growth phase were estimated to be 2.98 (95% confidence interval (CI): 2.73, 3.25), 2.38 (2.16, 2.60) and 2.20 (1.55, 2.84), the third method with the entire epidemic curve yielded a value of 3.53 (3.45, 3.62). This larger value could be an overestimate since the goodness-of-fit to the initial exponential phase worsened when we fitted the model to the entire epidemic curve, and because the model is established as an autonomous system without time-varying assumptions. These estimates were shown to be robust to parameter uncertainties, but the theoretical exponential-growth approximation (Method 1) shows wide uncertainty. Method 4 provided a maximum-likelihood effective reproduction number 2.10 (1.21, 2.95) using the first 17 epidemic days, which is consistent with estimates obtained from the other methods and an estimate of 2.36 (2.07, 2.65) for the entire autumn wave. We conclude that the reproduction number for pandemic influenza (Spanish flu) at the city level can be robustly assessed to lie in the range of 2.0-3.0, in broad agreement with previous estimates using distinct data.

Potential impact of pandemic influenza on blood safety and availability

The spread of H5N1, an avian influenza A virus, to many countries and the direct infection of humans by this virus have increased awareness of the likelihood of a pandemic among humans. The potential impact of pandemic influenza on the safety of the blood supply should be small because of the limited viremia and the nature of respiratory tract infection of influenza viruses. However, the potential impact of pandemic influenza on the availability of the blood supply could be significant because of reduced donation from blood donors and reduced staff capacity at blood centers during a pandemic. On the other hand, there could be reduced hospital admissions and reduced transfusions, at least for certain blood products, which should result in reduced demand for blood products. Studies are needed to further assess the likely impact of a pandemic on the blood supply and also of the possible intervention options.

Non-pharmaceutical interventions for pandemic influenza, international measures

Closing international borders was usually ineffective in past pandemics and would be less effective today.

Since global availability of vaccine and antiviral agents against influenza caused by novel human subtypes is insufficient, the World Health Organization (WHO) recommends nonpharmaceutical public health interventions to contain infection, delay spread, and reduce the impact of pandemic disease. Virus transmission characteristics will not be completely known in advance, but difficulties in influenza control typically include peak infectivity early in illness, a short interval between cases, and to a lesser extent, transmission from persons with incubating or asymptomatic infection. Screening and quarantining entering travelers at international borders did not substantially delay virus introduction in past pandemics, except in some island countries, and will likely be even less effective in the modern era. Instead, WHO recommends providing information to international travelers and possibly screening travelers departing countries with transmissible human infection. The principal focus of interventions against pandemic influenza spread should be at national and community levels rather than international borders.

Fatal avian influenza A (H5N1) in a child presenting with diarrhea followed by coma

In southern Vietnam, a four-year-old boy presented with severe diarrhea, followed by seizures, coma, and death. The cerebrospinal fluid contained 1 white cell per cubic millimeter, normal glucose levels, and increased levels of protein (0.81 g per liter). The diagnosis of avian influenza A (H5N1) was established by isolation of the virus from cerebrospinal fluid, fecal, throat, and serum specimens. The patient's nine-year-old sister had died from a similar syndrome two weeks earlier. In both siblings, the clinical diagnosis was acute encephalitis. Neither patient had respiratory symptoms at presentation. These cases suggest that the spectrum of influenza H5N1 is wider than previously thought.

Influenza virus and CNS manifestations

Neurological involvement during influenza infection has been described during epidemics and is often consistent with serious sequelae or death. An increasing incidence of influenza-associated encephalitis/encephalopathy has been reported in Japan, mainly in children. A variety of other clinical CNS manifestations, such as Reye's syndrome, acute necrotising encephalopathy (ANE), and myelitis as well as autoimmune conditions, such as Guillain-Barre's syndrome, may occur during the course of influenza infection. Virological diagnosis is essential and based on virus isolation, antigen detection, RNA detection by PCR, and serological analyses. Neuroimaging with CT and MRI of the brain are of prognostic value. The pathogenic mechanisms behind the influenza CNS complications are unknown. The treatment is symptomatic, with control of vital functions in the intensive care unit, antiepileptic medication and treatment against brain oedema.

Symptom pathogenesis during acute influenza: interleukin-6 and other cytokine responses

In experimental human influenza infection initiated by nasal inoculation, the magnitude of viral replication, fever, and symptoms correlate with nasopharyngeal lavage fluid levels of various cytokines. Our aim was to assess these relationships in patients with naturally occurring acute influenza. Patients with culture-positive influenza illness of less than 36 hr of duration were studied. Nasopharyngeal washing were collected at enrollment and on Day 2, 4, 6 and 8 for quantitative virus isolation and IL-6, TNF-alpha, INF-alpha, INF-gamma and IL-10 determinations. Blood samples collected at entry and on Day 2 and 6 were processed to assess plasma cytokines and circulating influenza RNA. Patients received either oseltamivir or placebo for 5 days. We assessed the correlation between nasopharyngeal lavage fluid or blood levels of cytokines before treatment and viral titers, symptom severity and fever. Sixteen adult subjects (median age of 22 years) were studied. In this small group of patients no significant differences between placebo and oseltamivir patients were found in viral replication or measures of cytokines. Thus the data for all 16 subjects were pooled for analysis. At entry, influenza A viruses were cultured from nasopharyngeal washes at a median titer of 4.8 log(10)TCID(50)/ml of wash. Viral titers correlated positively with symptom score (P = 0.006) and temperature values (P < 0.001). Viral titers, fever and symptoms were highest at enrollment and fell in parallel during the subsequent days. RT-PCR assays failed to detect influenza RNA in the white blood cells from any patient. We observed a significant release, in both nasopharyngeal lavage fluid and in plasma, of IL-6, TNF-alpha, INF-alpha, INF-gamma and IL-10. At entry high IL-6 levels were detected in the nasopharyngeal lavage fluid (median 10.3 pg/ml) and plasma (median 5.1 pg/ml) of all patients. We found a positive correlation between plasma IL-6 levels and both symptom scores and temperature values (P < 0.05), as well as a positive correlation between nasopharyngeal lavage fluid levels of IL-6 and TNF-alpha and temperature (P < 0.05). We did not find significant associations between symptoms, fever and levels of INF-alpha, INF-gamma or IL-10. The magnitude of early decrease in viral titers correlated with initial levels of INF-gamma in nasopharyngeal lavage fluid (P < 0.05). Significant production of IL-6, TNF-alpha, INF-alpha, INF-gamma and IL-10 occurs in response to community acquired influenza A illness. As in experimental influenza, symptoms and fever in natural acute influenza correlate with the release of IL-6.

Immunization of pigs against influenza virus infection by DNA vaccine priming followed by killed-virus vaccine boosting

In a previous study of particle-mediated DNA vaccination of pigs, it was found that administration of an influenza virus hemagglutinin (HA) gene elicited low levels of virus-specific antibody, but did not provide significant protection from challenge infection (as evidenced by virus shedding in nasal secretions). However, the vaccinated pigs developed high antibody titers after exposure to the challenge virus, suggesting strong priming of humoral immune responses by DNA vaccination. In the present study, pigs given a conventional, inactivated influenza virus vaccine 4 weeks after a priming dose of HA DNA developed higher levels of virus-specific serum antibodies and were protected from challenge virus infection to a significantly greater degree than pigs that received two doses of DNA vaccine.

Influenza A pandemics of the 20th century with special reference to 1918: virology, pathology and epidemiology

Influenza A virus initiated worldwide epidemics (pandemics) in 1918, 1957, 1968 and 1977. A revised calculation of the 1918-1919 pandemic estimates that 40 million persons died and 500 million were infected. The mortalities in 1957 and 1968 were nearly 6 million. Biological and genetic characteristics of the causative agents of the more recent pandemics, have been well studied but little is known about the causative agent of the Great Pandemic in 1918. Genetic characterisation of the 1918 virus has been achieved by sourcing virus RNA from formalin fixed lung samples or by exhuming frozen victims of the outbreak from Arctic regions. Initial analysis of the HA gene from two USA sources indicates a virus related to swine and human influenza with no base insertion at the HA1-HA2 cleavage junction which, at least in avian influenza A, characterises high virulence. Important unanswered questions are whether the 1918 virus spread pantropically perhaps to include the brain and hence cause encephalitis including the later lethargic forms, or whether infection was confined to the respiratory tract. Re-examination of reports of respiratory disease in England and France in 1916-1917 may indicate a non-Spanish origin of the pandemic and a period of 2 years for the virus to be seeded worldwide. In contrast the other two pandemic viruses in 1957 and 1968 appeared to originate in Asia. New anti-neuraminidase drugs in conjunction with amantadine and novel developments with influenza vaccines would be expected to ameliorate the disease in a future pandemic.

A retrospective study of the relationship between childhood asthma and respiratory infection during gestation

BACKGROUND

Wheeze in children has been found to be associated with prior antepartum haemorrhage and raised levels of IgE in cord blood, and acute wheezing episodes are intimately linked with respiratory viral infections.

OBJECTIVE

To assess the relationship between maternal presentation with respiratory tract infections in pregnancy and childhood asthma, taking into account factors which could affect presentation.

METHODS

This was a case-control study of 200 asthmatic children, 5-16-year-old, age-matched with one control, having no recorded history of wheeze. Data on respiratory tract infections, maternal wheeze, atopy and smoking was collected from primary care records. Deprivation score was assessed according to small residential areas and subjects were equally distributed between four general practices in Plymouth, UK.

RESULTS

Presentation with respiratory tract infections during pregnancy was significantly associated with childhood asthma (OR 1.69, 95% confidence interval 1.05-2.77, P = 0.03). The association was marginally stronger for infections in the first trimester (OR 2.30, 95% CI 1.05-5.41, P = 0.04) and for those with cough during pregnancy (OR 2.24, 95% CI 1.23-4.22, P = 0.007). The associations remained significant after allowing for the effect of the independent variables (gender, maternal smoking, maternal wheeze, allergic rhinitis, eczema, asthma treatment in pregnancy and deprivation [Townsend] score), using multiple logistic regression analysis (ORs and 95% CIs 1.91, 1.14-3.22; 2.32, 1.01-5.34 and 2.29, 1.17-4.48, respectively). There was also an association between numbers of presentations with respiratory infections and childhood asthma (test for trend, P = 0.02).

CONCLUSIONS

This study has shown an association between presentation with respiratory infection during gestation and childhood asthma. The results were not affected by the other independent variable factors studied and therefore provide some evidence to support the theory that respiratory viruses may be implicated in the aetiology of asthma.

Viremia induced by influenza virus

A mouse model of influenza A/PR/8 virus infection was adopted to investigate the blood and various tissues of intranasally infected mice for the presence of viral RNA by using the nested polymerase chain reaction. The nucleoprotein gene was detected in the red blood cell fraction from 1 to 5 days post-inoculation, while it was found in the lung and brain up to 14 days and in the liver, spleen, kidney, heart, and skeletal muscle up to 7 days. The virus-specific messenger RNA was transiently found in these organs. When mice received the uv-inactivated virus, viremia did not occur. The prior transfer of the hyperimmune serum prevented pneumonia but not bronchitis, and viremia was totally abolished. These results suggest: (1) viremia occurs during the acute phase of infection, (2) the virus is present in various organs and there the virus gene is transiently expressed, and (3) the virus enters the blood stream possibly through capillaries of the infected alveolar wall. Viremia may influence the pathogenesis of influenza.

Virus infection of polarized epithelial cells

This chapter focuses on the interaction of viruses with epithelial cells. The role of specific pathways of virus entry and release in the pathogenesis of viral infection is examined together with the mechanisms utilized by viruses to circumvent the epithelial barrier. Polarized epithelial cells in culture, which can be grown on permeable supports, provide excellent systems for investigating the events in virus entry and release at the cellular level, and much information is being obtained using such systems. Much remains to be learned about the precise routes by which many viruses traverse the epithelial barrier to initiate their natural infection processes, although important information has been obtained in some systems. Another area of great interest for future investigation is the process of virus entry and release from other polarized cell types, including neuronal cells.

The effects of maternal influenzal viraemia in late gestation on the conceptus of the pregnant ferret

Pregnant ferrets were inoculated intra-cardially on day 30 of gestation with influenza virus. The animals were sacrificed on days 5 to 11 after inoculation and the products of conception including the uterus were examined virologically and histopathologically. The results indicate that the initial site of infection of the conceptus is the haemophagous organ and that spread occurs from this site to the endometrium, placental labyrinth and fetus. Lesions in the fetus are confined to the liver and respiratory tract. In the liver they may represent either a viral hepatitis or a secondary response to placental damage resulting in the stimulation of erythropoiesis. In the respiratory tract they first occur in the nasal sinuses and upper airways suggesting that infection is via the amniotic fluid rather than via the blood stream. The relevance of these findings to human pregnancy is discussed.

[Influenza]

Influenza is the last great uncontrolled plague of mankind. Pandemics and epidemics occur at regular time intervals. The influenza viruses are divided into the types A, B and C and show unique variability of their surface antigens (hemagglutinin and neuraminidase). Influenza viruses of type A show the largest degree of antigenic variation which, in turn, resulted in the definition of a number of subtypes, each comprising many strains. By comparison, influenza viruses of types B and C exhibit much less variation of their surface antigens. As a consequence, no subtypes but many different strains have been recognized. The degree of antigenic variation correlates with the epidemiologic significance of the virus types, type A being the most and type C the least important. Two different kinds of antigenic variation have been recognized: In the case of minor variation of one or both surface antigens, the term "antigenic drift" is employed. Antigenic drift occurs with all three types of virus, it is caused by point mutations which increase the chance of survival of mutants in the diseased host. In addition, influenza A viruses show sudden and complete changes of their surface antigens in regular time intervals, resulting in the appearance of new subtypes. This event is called "antigenic shift". The mechanisms responsible for antigenic shift are poorly understood, only. In addition to the recycling of preceding subtypes, reassortment resulting from double infection of cells with strains of human and animal origin are considered possible explanations. By use of modern DNA recombinant technology, the base sequences of a series of virus genes and, as a consequence, the amino acid sequence of the corresponding antigens have been determined. By means of monoclonal antibodies, the antigenic structure of many influenza antigens has been further elucidated. It can be expected that further research on the molecular basis of antigenic variation could finally result in an understanding of the causal mechanisms. It is an outstanding feature of the epidemiology of influenza A viruses that a family of related strains prevails for a certain period of time and disappears abruptly as a new subtype emerges.(ABSTRACT TRUNCATED AT 400 WORDS)

The local origin of the febrile response induced in ferrets during respiratory infection with a virulent influenza virus

Intranasal infection of ferrets with a virulent Clone (7a) of the recombinant influenza virus A/PR/8/34—A/England/939/69 (H₃N₂) produced a fever approximately 24 h in duration beginning about 29 h after infection. The origin of this fever has been investigated as an indication of what might happen in influenza in man.

The systemic production of fever by virus interaction with phagocytes in the reticuloendothelial system appeared unlikely because insufficient virus escaped into the bloodstream. Ten half-hourly i.v. injections of 10⁸ 50%0 Egg-Bit Infectious Doses (EBID₅₀) of virus were needed to produce a fever of short duration (3-8 h). Yet, after the intranasal infection, which results in the 24 h fever, the total virus content in the nasal mucosa was less than 10⁸ EBID₅₀ before the onset of fever and only reached 10^8.5 EBID₅₀ for 4 h during fever. Also, just before or during the fever produced by intranasal infection, influenza virus antigens could not be detected by fluorescent antibody in the spleens of the animals but were detected in animals receiving a single bloodstream injection of 10⁸ EBID₅₀ of virus.

Fever is more likely to result from release of leucocyte pyrogen by virus-phagocyte interaction in the upper respiratory tract. A pyrogen active in ferrets with the characteristics of leucocyte (endogenous) pyrogen was produced by incubating influenza virus with ferret peripheral phagocytes in vitro. A pyrogen with similar properties was released by incubation of nasal inflammatory cells collected from infected febrile ferrets and many of the cells were shown by fluorescent antibody to have interacted with influenza virus.

Influenza infections during pregnancy in the mouse

The effect of a sublethal dose (0-5 LD50) of influenza A/WSN (H0N1) administered intranasally in the 1st and 3rd weeks of pregnancy was studied in C3H inbred mice. Maternal and neonatal mortality rates were significantly increased by infections in the 3rd week of pregnancy, but not in the 1st week. Infections during the last part of the 1st week significantly depressed the growth rate of neonates. No evidence of viraemia, transplacental transmission or congenital malformations were observed from infections during either week. The results are discussed in terms of a possible model for human influenza infections during pregnancy to determine the potential risks to the mother, fetus and neonate.

Epidemics of haemorrhagic cystitis due to influenza A virus

The present communication describes studies on thirty-three patients with haemorrhagic cystitis. The current epidemic variant of influenza type A virus, A/Tehran/5/75 (H3N2) [antigenically similar to A/Port Chalmers/1/73 (H3N2)], was recovered from the throats of eighteen and the urine of three patients. HI antibody rises to A/Tehran/5/75 virus were detected in over 50% of the cystitis patients tested.

The pregnant ferret as a model for studying the congenital effects of influenza virus infection in utero: infection of foetal tissues in organ culture and in vivo

Organ cultures of ferret foetal tissues showed a similar pattern of susceptibility to influenza virus to that already observed for human foetal tissues (Rosztoczy et al., 1975); respiratory, alimentary and urogenital tissues supported the replication of influenza virus but nervous and lymphopoietic tissues (those which, in man, are associated with foetal or postnatal abnormalities) were insusceptible. In contrast to corresponding human tissues, ferret foetal placenta and amnion readily supported viral replication although both human and ferret umbilical cord were susceptible. In limited experiments, neither the membranes nor the susceptible foetal tissues became infected after intranasal inoculation of pregnant ferrets of various gestational ages. However, after intracardial inoculation of pregnant ferrets with high titre virus (ca 10(9) EBID50) virus was isolated from both foetal membranes and foetuses. The membranes became infected at early, middle and late gestation, but virus appeared to cross the placental barrier to infect foetal tissues only in late gestation. At this stage virus could be isolated not only from those foetal tissues (respiratory, alimentary and urogenital) susceptible in organ culture, but also in small amounts from tissues which were insusceptible in organ culture (heart, lymphopoietic and nervous tissue). Virus was also isolated from foetal membranes and foetuses of late gestation ferrets following intracardial inoculation with a one hundred-fold lower dose of virus which, unlike the higher dose, did not induce a maternal febrile response. The pregnant ferret appears to be a suitable model for investigating the effects on development of foetal infection with influenza virus but it may have disadvantages with regard to the nature and strength of the placental barrier.

The behaviour in ferrets of two closely related clones of influenza virus of differing virulence for man

Clones 7a and 64d of the recombinant influenza virus A/PR/8/34-A/England/939/69(H3N2) which are of different virulence for man as judged by clinical score (7a more virulent than 64d) showed similar differences in ferrets. With intranasal inoculation the approximate 50% minimal infectious doses of both clones were similar (between 10(0) and 10(2) EID(50)) as were their titres in nasal washes 24 h after inoculation and the histologically evident damage they caused in the nasal turbinates. However, clone 7a persisted in the nasal washes more than 64d and produced a more prolonged pyrexia. Furthermore, 7a consistently produced a lung infection which was produced only occasionally by 64d and then to a lesser extent than 7a. In contrast to nasal mucosa, histological damage in the lung was slight with both strains. Differences in replication of 7a and 64d in organ cultures of nasal turbinates appeared only after 24 h incubation. They were not sufficiently large to explain the markedly superior ability of 7a to persist in the nasal tract in vivo. This persistence, which coincides with the production of pyrexia, may be due to a greater ability of 7a to resist induced systemic host defences. Spasmodic isolations of infective virus of both clones were made from extra-respiratory tissues such as liver, spleen and kidney.

Effect of viral and bacterial pneumonias on cell-mediated immunity in humans

Cell-mediated immunity (CMI) was assessed during infection and after convalescence in 12 patients with influenza pneumonia and 10 patients with bacterial pneumonia. The patients with influenza pneumonia had a marked impairment of skin test reactivity, and their lymphocytes showed a diminished response to phytohemagglutinin and streptokinase-streptodornase stimulation in vitro. Suppression of CMI was related to the severity of the pneumonia. Patients with bacterial pneumonia showed as great a suppression of the response to phytohemagglutinin and streptokinase-streptodornase as the patients with viral pneumonia. All parameters of CMI returned to normal in both groups after convalescence. The depression of CMI could not be related to a decrease in the number of thymus-derived lymphocytes or to serum-suppressive factors in these patients.

Replication of influenza virus in organ cultures of human and simian urogenital tissues and human foetal tissues

A survey of human adult tissues in organ cultures showed that influenza viruses (A/Moscow/1019/65 (h2n2) or a recombinant virus virulent for man (PR/8-A/England/939/69 Clone 7a(H3N2)) could infect uterus, bladder and conjunctiva but not oesophagus under the conditions employed; simian bladder and uterus were also susceptible. These results were similar to those already described for corresponding ferret tissues. Organ cultures of human foetal nasal mucosa, trachea, oesophagus, small and large intestine, and bladder consistently supported replication over 4 days or more with high virus yields. Lung, conjunctiva and umbilical cord were less consistently susceptible and gave lower yields. Placenta and kidney cultures allowed replication of virus in one of 8 and one of 4 experiments respectively, the yields being low and of short duration. Organ cultures of neural tissue (meninges and brain), lymphopoietic tissue (spleen, liver and thymus) and amnion did not support significant viral replication. The results are discussed in relation to possible infection of the foetus in utero with influenza virus.

Dissemination of influenza virus between anatomically isolated sites in ferrets

Influenza virus was shown to disseminate from the respiratory tract of nasally infected ferrets to a surgically formed, subcutaneous tracheal pouch. Conversely, ferrets infected via the pouch shed virus from the upper respiratory tract. These events occurred within the first 24 h after infection. Passively administered ferret antibody to virus did not prevent the dissemination.

Rhinoviraemia

Rhinoviruses have been isolated from the serum of two infants at necropsy. Failure to isolate viruses from ten other sera from infants who yielded rhinoviruses from their respiratory tracts suggests that true rhinoviraemia occurs rarely, and is infrequently associated with rhinovirus infections, both clinical and subclinical, and death. It is suggested that this is the first report of isolations of human rhinoviruses from the blood.