Influenza A virus (IAV) is a pathogen with strains that infect birds and some mammals, as well as causing seasonal flu in humans.[1] Mammals in which different strains of IAV circulate with sustained transmission are bats, pigs, horses and dogs; other mammals can occasionally become infected.[2][3]
IAV is an envelopednegative-senseRNA virus, with a segmented genome.[3] Through a combination of mutation and genetic reassortment the virus can evolve to acquire new characteristics, enabling it to evade host immunity and occasionally to jump from one species of host to another.[4][5]
Subtypes of IAV are defined by the combination of the antigenic H and N proteins in the viral envelope; for example, "H1N1" designates an IAV subtype that has a type-1 hemagglutinin (H) protein and a type-1 neuraminidase (N) protein.[6] Almost all possible combinations of H (1 thru 16) and N (1 thru 11) have been isolated from wild birds.[7] Further variations exist within the subtypes and can lead to very significant differences in the virus's ability to infect and cause disease, as well as to the severity of symptoms.[8][9]
Symptoms of human seasonal flu usually include fever, cough, sore throat, muscle aches, conjunctivitis and, in severe cases, breathing problems and pneumonia that may be fatal.[10][11] Humans can rarely become infected with strains of avian or swine influenza, usually as a result of close contact with infected animals; symptoms range from mild to severe including death.[12][13] Bird-adapted strains of the virus can be asymptomatic in some aquatic birds but lethal if they spread to other species, such as chickens.[14]
IAV disease in poultry can be can be prevented by vaccination, however biosecurity control measures are preferred.[15][16] In humans, seasonal influenza can be treated in its early stages with antiviral medicines.[17] A global network, the Global Influenza Surveillance and Response System (GISRS) monitors the spread of influenza with the aim to inform development of both seasonal and pandemic vaccines.[18] Several millions of specimens are tested by the GISRS network annually through a network of laboratories in 127 countries. As well as human viruses, GISRS monitors avian, swine, and other potentially zoonotic influenza viruses. IAV vaccines need to be reformulated regularly in order to keep up with changes in the virus.[19]
Influenza A virus is the only species of the genusAlphainfluenzavirus of the virus family Orthomyxoviridae.[20] There are two methods of classification, one based on surface proteins (originally serotypes),[21] and the other based on its behavior, mainly the host animal.
There are two antigenicproteins on the surface of the viral envelope, hemagglutinin and neuraminidase[22] Different influenza virus genomes encode different hemagglutinin and neuraminidase proteins. Based on their serotype, there are 18 known types of hemagglutinin and 11 types of neuraminidase.[23][24] Subtypes of IAV are classified by their combination of H and N proteins. For example, "H5N1" designates an influenza A subtype that has a type-5 hemagglutinin (H) protein and a type-1 neuraminidase (N) protein.[23] Further variations exist within the subtypes and can lead to very significant differences in the virus's behavior.[25]
By definition, the subtyping scheme only takes into account the two outer proteins, not the at least 8 proteins internal to the virus.[26] Almost all possible combinations of H (1 thru 16) and N (1 thru 11) have been isolated from wild birds.[27] H17 and H18 have only been discovered in bats.[28]
Due to the high variability of the virus, subtyping is not sufficient to uniquely identify a strain of influenza A virus. To unambiguously describe a specific isolate of virus, researchers use the Influenza virus nomenclature,[29] which describes, among other things, the subtype, year, and place of collection. Some examples include:[30]
The starting A indicates that the virus is an influenza A virus.
Rio de Janeiro indicates the place of collection. 62434 is a laboratory sequence number. 2021 (or just 21) indicates that the sample was collected in 2021. No species is mentioned so by default, the sample was collected from a human.
This example carries an unusual designation in the last part: instead of a usual (H1N1), it uses A(H1N1)pdm09. This was in order to distinguish the Pandemic H1N1/09 virus lineage from older H1N1 viruses.[30]
The influenza A virus has a negative-sense, single-stranded, segmented RNA genome, enclosed in a protein envelope. The virus particle (also called the virion) is 80–120 nanometers in diameter such that the smallest virions adopt an elliptical shape; larger virions have a filamentous shape.[31] The viral envelope comprises two main proteins; hemagglutinin (HA) and neuraminidase (NA). HA is a protein that binds the virion to host cells, enabling the RNA genetic material to invade it. Once the host cell has started manufacturing the components of new virions, NA enables the newly assembled virions to escape the host cell and go on to propagate the infection. Both proteins are antigenic; a host's immune system can react to them and produce antibodies in response.[32]
The central core of the virion contains the genetic material and the viral proteins that package and protect it. Unlike the genomes of most organisms (including humans, animals, plants, and bacteria) which are made up of double-stranded DNA, many viral genomes are made up of a different, single-stranded nucleic acid called RNA. Unusually for a virus, though, the influenza type A virus genome is not a single piece of RNA; instead, it consists of 8 segments of RNA, each piece containing either one or two genes which code for a gene product (protein).[33] The segmented nature of the genome allows for the exchange of entire genes between different viral strains.[33][34][32]
The predominant natural reservoir of influenza viruses is thought to be wild waterfowl.[35] The subtypes of influenza A virus are estimated to have diverged 2,000 years ago. Influenza viruses A and B are estimated to have diverged from a single ancestor around 4,000 years ago, while the ancestor of influenza viruses A and B and the ancestor of influenza virus C are estimated to have diverged from a common ancestor around 8,000 years ago.[36]
Outbreaks of influenza-like disease can be found throughout recorded history. The first probable record is by Hippocrates in 142 BCE.[37] The historian Fujikawa listed 46 epidemics of flu-like illness in Japan between 862 and 1868.[38] In Europe and the Americas, a number of epidemics were recorded through the Middle Ages and up to the end of the 19th century.[37]
In 1918-1919 came the first flu pandemic of the 20th century, known generally as the "Spanish flu", which caused an estimated 20 to 50 million deaths worldwide. It is now known that this was caused by an immunologically novel H1N1 subtype of influenza A.[39] The next pandemic took place in 1957, the "Asian flu", which was caused by a H2N2 subtype of the virus in which the genome segments coding for HA and NA appeared to have derived from avian influenza strains by reassortment, while the remainder of the genome was descended from the 1918 virus.[40] The 1968 pandemic ("Hong Kong flu") was caused by a H3N2 subtype in which the NA segment was derived from the 1957 virus, while the HA segment had been reassorted from an avian strain of influenza.[40]
In the 21st century, a strain of H1N1 flu (since titled H1N1pdm09) which was antigenically very different from previous H1N1 strains, leading to a pandemic in 2009. Because of its close resemblance to some strains circulating in pigs, this became known as "Swine flu"[41]
Influenza A virus continues to circulate and evolve in birds and pigs. Almost all possible combinations of H (1 thru 16) and N (1 thru 11) have been isolated from wild birds.[27] As of June 2024, two particularly virulent IAV strains - H5N1 and H7N9 - are predominant in wild bird populations. These frequently cause outbreaks in domestic poultry, with occasional spillover infections in humans who are in close contact with poultry.[42][43]
The annual cycle of flu in humans in the US "results in approximately 36,000 deaths and more than 200,000 hospitalizations each year. In addition to this human toll, influenza is annually responsible for a total cost of over $10 billion in the U.S."[44] Globally the toll of influenza virus is estimated at 290,000–645,000 deaths annually, exceeding previous estimates.[45]
The annually updated, trivalent influenza vaccine consists of hemagglutinin (HA) surface glycoprotein components from influenza H3N2, H1N1, and B influenza viruses.[46] For example, the World Health Organization recommends flu shots for the 2023-2024 flu season in northern hemisphere to use the A/Darwin/9/2021 (H3N2)-like virus.[47]
Timeline of flu pandemics and epidemics caused by influenza A virus
"Human influenza virus" usually refers to those subtypes that spread widely among humans. H1N1, H1N2, and H3N2 are the only known influenza A virus subtypes circulating among humans.[48]
Human flu symptoms usually include fever, cough, sore throat, muscle aches, conjunctivitis and, in severe cases, breathing problems and pneumonia that may be fatal. The severity of the infection will depend in large part on the state of the infected person's immune system and if the victim has been exposed to the strain before, and is therefore partially immune.[citation needed] Follow-up studies on the impact of statins on influenza virus replication show that pre-treatment of cells with atorvastatin suppresses virus growth in culture.[49]
The influenza A virus subtypes that have been confirmed in humans are:
Confirmed human cases and fatalities caused by different influenza A virus zoonoses up to 2018. (# of cases / # of fatalities)H1N1 was responsible for the 2009 pandemic in both human and pig populations. A variant of H1N1 was responsible for the Spanish flu pandemic that killed some 50 million to 100 million people worldwide over about a year in 1918 and 1919.[54] Another variant was named a pandemic threat in the 2009 flu pandemic. Controversy arose in October 2005, after the H1N1 genome was published because of fears that this information could be used for bioterrorism.[55]
H3N2 is endemic in both human and pig populations. It evolved from H2N2 by antigenic shift and caused the Hong Kong flu pandemic of 1968, and 1969, that killed up to 750,000.[57] A severe form of the H3N2 virus killed several children in the United States in late 2003.[58]
The dominant strain of annual flu in January 2006 was H3N2. Measured resistance to the standard antiviral drugs amantadine and rimantadine in H3N2 increased from 1% in 1994 to 12% in 2003 to 91% in 2005.[59][60] Human H3N2 influenza viruses are now[when?] endemic in pigs in southern China, where they circulate together with avian H5N1 viruses.[61]
Japan's Health Ministry said January 2006 that poultry farm workers in Ibaraki prefecture may have been exposed to H5N2 in 2005.[62] The H5N2 antibody titers of paired sera of 13 subjects increased fourfold or more.[63]
In February 2021, Russia reported the first known cases of H5N8 in humans. Seven people were confirmed to have been infected in December 2020 and have since recovered.[64] There was no indication of human-to-human transmission.[65]
In North America, the presence of avian influenza strain H7N3 was confirmed at several poultry farms in British Columbia in February 2004. As of April 2004, 18 farms had been quarantined to halt the spread of the virus. Two cases of humans with avian influenza have been confirmed in that region. "Symptoms included conjunctivitis and mild influenza-like illness."[67]
On 2 April 2013, the Centre for Health Protection (CHP) of the Department of Health of Hong Kong confirmed four more cases in Jiangsu province in addition to the three cases initially reported on 31 March 2013.[68] This virus also has the greatest potential for an influenza pandemic among all of the Influenza A subtypes.[69]
In 2004, in Egypt, H10N7 was reported for the first time in humans. It caused illness in two infants in Egypt. One child's father was a poultry merchant.[70]
See H5N1 for the epizootic (an epidemic in nonhumans) and panzootic (a disease affecting animals of many species especially over a wide area) of H5N1 influenza
Fowl act as natural asymptomatic carriers of influenza A viruses. Prior to the H5N1 epizootic, strains of influenza A virus had been demonstrated to be transmitted from wildfowl to only birds, pigs, horses, seals, whales and humans; and only between humans and pigs and between humans and domestic fowl; and not other pathways such as domestic fowl to horse.[72]
Wild aquatic birds are the natural hosts for a large variety of influenza A viruses. Occasionally, viruses are transmitted from these birds to other species and may then cause devastating outbreaks in domestic poultry or give rise to human influenza pandemics.[73][74]
H5N1 has been shown to be transmitted to tigers, leopards, and domestic cats that were fed uncooked domestic fowl (chickens) with the virus. H3N8 viruses from horses have crossed over and caused outbreaks in dogs. Laboratory mice have been infected successfully with a variety of avian flu genotypes.[75]
Known outbreaks of highly pathogenic flu in poultry 1959–2003[76]
*Outbreaks with significant spread to numerous farms, resulting in great economic losses. Most other outbreaks involved little or no spread from the initially infected farms.
More than 400 harbor seal deaths were recorded in New England between December 1979 and October 1980, from acute pneumonia caused by the influenza virus, A/Seal/Mass/1/180 (H7N7).[77]
Swine influenza (or "pig influenza") refers to a subset of Orthomyxoviridae that create influenza and are endemic in pigs. The species of Orthomyxoviridae that can cause flu in pigs are influenza A virus and influenza C virus, but not all genotypes of these two species infect pigs. The known subtypes of influenza A virus that create influenza and are endemic in pigs are H1N1, H1N2, H3N1 and H3N2. In 1997, H3N2 viruses from humans entered the pig population, causing widespread disease among pigs.[78][failed verification]
Horse flu (or "equine influenza") refers to varieties of influenza A virus that affect horses. Horse flu viruses were only isolated in 1956. The two main types of virus are called equine-1 (H7N7), which commonly affects horse heart muscle, and equine-2 (H3N8), which is usually more severe. H3N8 viruses from horses have infected dogs.[78][failed verification]
Bat flu (or "Bat influenza") refers to the H17N10 and H18N11 influenza A virus strains that were discovered in Central and South American fruit bats as well as a H9N2 virus isolated from the Egyptian fruit bat.[79] Until now it is unclear whether these bat-derived viruses are circulating in any non-bat species and whether they pose a zoonotic threat. Initial characterization of the H18N11 subtype, however, suggests that this bat influenza virus is not well adapted to any other species than bats.[80]
FI6, an antibody that targets the hemagglutinin protein, was discovered in 2011. FI6 is the only known antibody effective against all 16 subtypes of the influenza A virus.[81][82][83]
^Knobler SL, Mack A, Mahmoud A, et al., eds. (2005). "1, The Story of Influenza.". The Threat of Pandemic Influenza: Are We Ready? Workshop Summary. Institute of Medicine (US) Forum on Microbial Threats. Washington (DC): National Academies Press (US).
^ abThreats Io, Knobler SL, Mack A, Mahmoud A, Lemon SM (2005), "The Story of Influenza", The Threat of Pandemic Influenza: Are We Ready? Workshop Summary, National Academies Press (US), retrieved 20 June 2024
^Daum LT, Shaw MW, Klimov AI, Canas LC, Macias EA, Niemeyer D, et al. (August 2005). "Influenza A (H3N2) outbreak, Nepal". Emerging Infectious Diseases. 11 (8): 1186–91. doi:10.3201/eid1108.050302. PMC3320503. PMID16102305. "The 2003–2004 influenza season was severe in terms of its impact on illness because of widespread circulation of antigenically distinct influenza A (H3N2) Fujian-like viruses. These viruses first appeared late during the 2002–2003 influenza season and continued to persist as the dominant circulating strain throughout the subsequent 2003–2004 influenza season, replacing the A/Panama/2007/99-like H3N2 viruses (1). Of the 172 H3N2 viruses genetically characterized by the Department of Defense in 2003–2004, only one isolate (from Thailand) belonged to the A/Panama-like lineage. In February 2003, the World Health Organization (WHO) changed the H3N2 component for the 2004–2005 influenza vaccine to afford protection against the widespread emergence of Fujian-like viruses (2). The annually updated trivalent vaccine consists of hemagglutinin (HA) surface glycoprotein components from influenza H3N2, H1N1, and B viruses."
^"Making the leap". Harvard T.H. Chan School of Public Health. 24 October 2013. Archived from the original on 3 January 2021. Retrieved 6 December 2020.
^Detailed chart of its evolution hereArchived 9 May 2009 at the Wayback Machine at PDF called Ecology and Evolution of the Flu
^Mahmoud 2005, p. 115 "There is particular pressure to recognize and heed the lessons of past influenza pandemics in the shadow of the worrisome 2003–2004 flu season. An early-onset, severe form of influenza A H3N2 made headlines when it claimed the lives of several children in the United States in late 2003. As a result, stronger than usual demand for annual flu inactivated vaccine outstripped the vaccine supply, of which 10 to 20 percent typically goes unused. Because statistics on pediatric flu deaths had not been collected previously, it is unknown if the 2003–2004 season witnessed a significant change in mortality patterns."
^Mahmoud 2005, p. 126 "H5N1 virus is now endemic in poultry in Asia (Table 2-1) and has gained an entrenched ecological niche from which to present a long-term pandemic threat to humans. At present, these viruses are poorly transmitted from poultry to humans, and there is no conclusive evidence of human-to-human transmission. However, continued, extensive exposure of the human population to H5N1 viruses increases the likelihood that the viruses will acquire the necessary characteristics for efficient human-to-human transmission through genetic mutation or reassortment with a prevailing human influenza A virus. Furthermore, contemporary human H3N2 influenza viruses are now endemic in pigs in southern China (Peiris et al., 2001) and can reassort with avian H5N1 viruses in this 'intermediate host.' Therefore, it is imperative that outbreaks of H5N1 disease in poultry in Asia are rapidly and sustainably controlled. The seasonality of the disease in poultry, together with the control measures already implemented, are likely to reduce temporarily the frequency of H5N1 influenza outbreaks and the probability of human infection."
^Mahmoud 2005, p. 82 "Interestingly, recombinant influenza viruses containing the 1918 HA and NA and up to three additional genes derived from the 1918 virus (the other genes being derived from the A/WSN/33 virus) were all highly virulent in mice (Tumpey et al., 2004). Furthermore, expression microarray analysis performed on whole lung tissue of mice infected with the 1918 HA/ NA recombinant showed increased upregulation of genes involved in apoptosis, tissue injury, and oxidative damage (Kash et al., 2004). These findings were unusual because the viruses with the 1918 genes had not been adapted to mice. The completion of the sequence of the entire genome of the 1918 virus and the reconstruction and characterization of viruses with 1918 genes under appropriate biosafety conditions will shed more light on these findings and should allow a definitive examination of this explanation. Antigenic analysis of recombinant viruses possessing the 1918 HA and NA by hemagglutination inhibition tests using ferret and chicken antisera suggested a close relationship with the A/swine/Iowa/30 virus and H1N1 viruses isolated in the 1930s (Tumpey et al., 2004), further supporting data of Shope from the 1930s (Shope, 1936). Interestingly, when mice were immunized with different H1N1 virus strains, challenge studies using the 1918-like viruses revealed partial protection by this treatment, suggesting that vaccination strategies are adequate against a 1918-like virus (Tumpey et al., 2004)."
^Geraci JR, St Aubin DJ, Barker IK, Webster RG, Hinshaw VS, Bean WJ, et al. (February 1982). "Mass mortality of harbor seals: pneumonia associated with influenza A virus". Science. 215 (4536): 1129–31. Bibcode:1982Sci...215.1129G. doi:10.1126/science.7063847. PMID7063847. More than 400 harbor seals, most of them immature, died along the New England coast between December 1979 and October 1980 of acute pneumonia associated with influenza virus, A/Seal/Mass/1/180 (H7N7). The virus has avian characteristics, replicates principally in mammals, and causes mild respiratory disease in experimentally infected seals. Concurrent infection with a previously undescribed mycoplasma or adverse environmental conditions may have triggered the epizootic. The similarities between this epizootic and other seal mortalities in the past suggest that these events may be linked by common biological and environmental factors.
^ abCDCArchived 6 May 2015 at the Wayback Machine Centers for Disease Control and Prevention – Transmission of Influenza A Viruses Between Animals and People
Beigel JH, Farrar J, Han AM, Hayden FG, Hyer R, de Jong MD, et al. (September 2005). "Avian influenza A (H5N1) infection in humans". The New England Journal of Medicine. 353 (13): 1374–85. CiteSeerX10.1.1.730.7890. doi:10.1056/NEJMra052211. PMID16192482.
Mahmoud (2005). Stacey L. Knobler, Alison Mack, Mahmoud A, Stanley M. Lemon (eds.). The threat of pandemic influenza : are we ready? : workshop summary / prepared for Forum on Microbial Threats, Board on Global Health. The National Academies Press. p. 285. ISBN0-309-09504-2. Highly pathogenic avian influenza virus is on every top ten list available for potential agricultural bioweapon agents
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