Orthomyxoviruses

(Influenza Viruses)
A 32-year-old male physician developed a “flu-like” syndrome with fever, sore throat,
headache, and myalgia. To provide laboratory confirmation of influenza, a culture for the
virus was ordered. Which would be the best specimen for isolating the virus responsible for
this infection?
 Respiratory illnesses are responsible for more than half of all acute illnesses each
year in the United States.
The Orthomyxoviridae (influenza viruses) are a major determinant of morbidity and
mortality caused by respiratory disease, and outbreaks of infection sometimes occur
in worldwide epidemics.
Influenza has been responsible for millions of deaths worldwide.
Mutability and high frequency of genetic reassortment and resultant antigenic changes in
the viral surface glycoproteins make influenza viruses formidable challenges for
control efforts.
 Influenza type A is antigenically highly variable and is responsible for most cases
of epidemic influenza.
 Influenza type B may exhibit antigenic changes and sometimes causes epidemics.
 Influenza type C is antigenically stable and causes only mild illness in
immunocompetent individuals.
 Three immunologic types of influenza viruses
are known, designated A, B, and C. Whereas
antigenic changes continually occur within the type
A group of influenza viruses and to a lesser degree
in the type B group, type C appears to be
antigenically stable.

 Influenza virus particles are usually spherical and about 100

nm in diameter (80–120 nm), although virions may display
great variation in size.
 The single-stranded, negative-sense RNA genomes of
influenza A and B viruses occur as eight separate segments;
influenza C viruses contain seven segments of RNA, lacking a
neuraminidase gene.
 Influenza virus particles contain nine different structural proteins.
The nucleoprotein (NP) associates with the viral RNA to form a ribonucleoprotein (RNP) structure 9 nm in
diameter that assumes a helical configuration and forms the viral nucleocapsid.
Three large proteins (PB1, PB2, and PA) are bound to the viral RNP and are responsible for RNA transcription and
replication.
The matrix (M 1 ) protein, which forms a shell underneath the viral lipid envelope, is important in particle
morphogenesis and is a major component of the virion (∼40% of viral protein).

Two virus-encoded glycoproteins, hemagglutinin (HA) and

neuraminidase (NA), are inserted into the envelope and are
exposed as spikes about 10 nm long on the surface of the
particle.
These two surface glycoproteins are the important antigens
that determine antigenic variation of influenza viruses and
host immunity.
The M 2 ion channel protein and the NS 2 protein are also
present in the envelope but at only a few copies per particle.
Because of the segmented nature of the genome, when a
cell is coinfected by two different viruses of a given type,
mixtures of parental gene segments may be assembled into
progeny virions. This phenomenon, called genetic
reassortment, may result in sudden changes in viral surface
antigens—a property that explains the epidemiologic features
of influenza and poses significant problems for vaccine
development.
 Classification and Nomenclature

Genus Influenzavirus A contains human and animal strains

of influenza type A, Influenzavirus B contains human strains
of type B, and Influenzavirus C contains influenza type C
viruses of humans and swine.
Antigenic differences exhibited by two of the internal
structural proteins, the nucleocapsid (NP) and matrix (M)
proteins, are used to divide influenza viruses into types A, B,
and C. These proteins possess no cross-reactivity among the
three types. Antigenic variations in the surface glycoproteins,
HA and NA, are used to subtype the viruses. Only type A has
designated subtypes.
The standard nomenclature system for influenza virus
isolates includes the following information: type, host of origin,
geographic origin, strain number, and year of isolation.
Antigenic descriptions of the HA and the NA are given in
parentheses for type A.
So far, 15 subtypes of HA (H1–H15) and nine subtypes
of NA (N1–N9), in many different combinations, have been
recovered from birds, animals, or humans. Four HA (H1–H3,
H5) and two NA (N1, N2) subtypes have been recovered from
humans.
Influenza Virus Replication
 Viral Attachment, Penetration, and Uncoating

The virus attaches to cell-surface sialic acid via the receptor

site located on the top of the large globule of the HA. Virus
particles are then internalized within endosomes by a process
called receptor-mediated endocytosis. The next step involves
fusion between the viral envelope and cell membrane,
triggering uncoating. The low pH within the endosome is
required for virus-mediated membrane fusion that releases
viral RNPs into the cytosol. Acid pH causes a conformational
change in the HA structure to bring the HA2 “fusion peptide” in
correct contact with the membrane. The M 2 ion channel
protein present in the virion permits the entry of ions from the
endosome into the virus particle, triggering the conformational
change in HA. Viral nucleocapsids are then released into the
cell cytoplasm.
 Transcription and Translation

Transcription mechanisms used by orthomyxoviruses differ markedly from those of

other RNA viruses in that cellular functions are more intimately involved. Viral
transcription occurs in the nucleus. The mRNAs are produced from viral
nucleocapsids. The virus-encoded polymerase, consisting of a complex of the
three P proteins, is primarily responsible for transcription. Six of the genome
segments yield monocistronic mRNAs that are translated in the cytoplasm into six
viral proteins. The other two transcripts undergo splicing, each yielding two mRNAs
that are translated in different reading frames. At early times after infection,
the NS 1 and NP proteins are preferentially synthesized. At later times, the
structural proteins are synthesized at high rates. The two glycoproteins, HA and
NA, are modified using the secretory pathway.

Maturation

The virus matures by budding from the surface of the cell.

 Pathogenesis and Pathology
Influenza virus spreads from person to person by airborne droplets or by contact with contaminated hands or
surfaces. Progeny virions are soon produced and spread to adjacent cells, where the replicative cycle is
repeated. Viral NA lowers the viscosity of the mucous film in the respiratory tract, laying bare the cellular
surface receptors and promoting the spread of virus-containing fluid to lower portions of the tract. Within a
short time, many cells in the respiratory tract are infected and eventually killed.
The incubation period from exposure to virus and the
onset of illness varies from 1 day to 4 days, depending on the
size of the viral dose and the immune status of the host. Viral
shedding starts the day preceding onset of symptoms, peaks
within 24 hours, remains elevated for 1–2 days, and then
declines over the next 5 days. Specific antibody and cell-
mediated responses cannot be detected for another 1–2
weeks.
Influenza infections cause cellular destruction and des -
quamation of superficial mucosa of the respiratory tract but
do not affect the basal layer of epithelium. Complete repara -
tion of cellular damage probably takes up to 1 month. Viral
damage to the respiratory tract epithelium lowers its resis-
tance to secondary bacterial invaders, especially staphylo-
cocci, streptococci, and Haemophilus influenzae.
 Clinical Findings
Influenza attacks mainly the upper respiratory tract. It poses a serious risk for elderly adults, very young
children, and people with underlying medical conditions such as lung, kidney, or heart problems, diabetes, or
cancer.
Uncomplicated Influenza
Symptoms of classic influenza usually appear abruptly and include
 chills,
 headache, and
 dry cough followed closely by
 high fever,
 generalized muscular aches,
 malaise, and
 anorexia.

The fever usually lasts 3–5 days, as do the systemic symptoms. Respiratory
symptoms typically last another 3–4 days. The cough and weakness may persist for
2–4 weeks after major symptoms subside. Mild or asymptomatic infections
may occur.
Influenza A viruses are an important cause of croup, which may be severe, in
children younger than 1 year of age. Finally, otitis media may develop.
 Pneumonia
Serious complications usually occur only in elderly adults
and debilitated individuals, especially those with underlying
chronic disease. Pregnancy appears to be a risk factor for
lethal pulmonary complications in some epidemics.
Pneumonia complicating influenza infections can be
 viral,
 secondary bacterial, or
 a combination of the two.
Increased mucous secretion helps carry agents into the lower
respiratory tract. Influenza infection enhances susceptibility
of patients to bacterial superinfection. This is attributed to
 loss of ciliary clearance,
 dysfunction of phagocytic cells, and
 provision of a rich bacterial growth medium by the
alveolar exudate.
Bacterial pathogens are most often
 Staphylococcus
 aureus,
 Streptococcus pneumoniae, and
 H influenzae.
Combined viral–bacterial pneumonia is approximately
three times more common than primary influenza pneumonia.
 Reye Syndrome
Reye syndrome is an acute encephalopathy of children and
adolescents, usually between 2 and 16 years of age. The
mortality rate is high (10–40%). The cause of Reye syndrome is
unknown, but it is a recognized rare complication of influenza
B, influenza A, and herpesvirus varicella-zoster infections.
There is a possible relationship between salicylate use and
subsequent development of Reye syndrome. The incidence of
the syndrome has decreased with the reduced use of
salicylates in children with flu-like symptoms.
Amantadine hydrochloride and an analog,
rimantadine, classed as adamantane drugs, are
M 2 ion channel inhibitors for systemic use in
the treatment and prophylaxis of influenza A. The
NA inhibitors zanamivir and oseltamivir were
approved in 1999 for treatment of both
influenza A and influenza B.
 Laboratory Diagnosis
Clinical characteristics of viral respiratory infections can be produced by many different viruses.
Nasal washings, gargles, and throat swabs are the best specimens for diagnostic testing and should be
obtained within 3 days after the onset of symptoms.

 Polymerase Chain Reaction

 Isolation and Identification of Virus
 Serology - Antibodies to several viral proteins (hemagglutinin, neuraminidase,
nucleoprotein, and matrix) are produced during infection with influenza virus. The
immune response against the HA glycoprotein is associated with resistance to
infection.

Prevention
Inactivated Viral Vaccines - The vaccine is usually a cocktail containing one or two type A
viruses and a type B virus of the strains isolated in the previous winter’s outbreaks.
Live-Virus Vaccines - A live attenuated, cold-adapted, temperature-sensitive, trivalent
influenza virus vaccine administered by nasal spray was licensed in the United States in 2003.
Annual influenza vaccination is recommended for all children ages 6 months to 18 years
and for high-risk groups.
(A) Stool
(B) Nasopharyngeal washing
(C) Vesicle fluid
(D) Blood
(E) Saliva
Thanks for your attention