Indian Journal of Medical Microbiology, (2004) 22 (3):143-146

Review Article

AVIAN INFLUENZA A (H5N1): A PRELIMINARY REVIEW

*S Padhi, PK Panigrahi, A Mahapatra, S Mahapatra

Abstract
Humanity has been at the receiving end of many viral diseases since ages. Sudden emergence and re-emergence
of new viral diseases in human beings has surprised the medical scientists from time to time. “Avian influenza”
or “Bird flu” by H5N1 epidemics is one such surprise. Although many aspects about this disease are clear,
there are some dark areas regarding vaccine development that need to be further explored and understood, so as
to effectively contain the spread of this disease. The present article details out almost everything known about
this interesting disease along with the review of the recent literature.

Key words: Avian influenza, influenza A (H5N1), epidemic

“Avian influenza” or “Bird flu” is an infectious some health experts, the vaccination of birds in China
disease of birds, ranging from a mild to a severe form of could have contributed to the current problem.3
illness. It is caused by 15 subtypes of the influenza A
virus, subtype of avian influenza. Viruses of low The present outbreak was first reported in poultry
pathogenicity can, after circulation for some time in a of Thailand as chicken cholera in November 2003. On
poultry population, mutate into highly pathogenic 15th December 2003, South Korea confirmed that the
viruses. To date, all outbreaks of the highly pathogenic outbreak was, infact ‘avian flu’. On 23rd January 2004,
form have been caused by influenza A/H5N1 virus, the Thailand confirmed the first human case of ‘avian-flu’.4
only subtype that causes outbreaks of severe disease At present, it has spread to countries such as Vietnam,
in humans.1 The ability of the strain H5N1 to evade the Cambodia, Taiwan, Japan, South Korea, China,
body’s defence mechanism by evading cytokines (the Hongkong, Indonesia and Laos. It is believed that
first line of defence against ‘flu’) may be responsible for migratory wildfowl, which can carry numerous viruses
the high pathogenicity of this particular strain.2 without being infected, are most likely to blame for the
initial spread of the disease. Other factors – the transport
The ‘bird flu’, now sweeping many countries of of infected chickens across borders, both legally and
Asia, is caused by the H5N1 strain of the influenza A illegally, as well as months of government inactivity
virus. Like Severe Acute Respiratory Syndrome (SARS), despite mounting evidence of avian flu outbreaks- came
bird flu is suspected to have originated in China, into play to produce the current problem.5 Human cases
probably in the first half of 2003.3 Avian flu first ‘jumped’ have been reported only in Thailand and Vietnam,
the “species barrier” from birds to humans in 1997 and whereas in other countries only infection in poultry has
caused an outbreak in Hongkong.2 Following the death been reported.6 Till 10th February 2004, the death toll in
of six people by H5N1 bird flu, Hongkong conducted a humans from the disease had been 18 and tens of
mass slaughter of chickens. To protect its poultry, thousands of chickens had been killed to keep the
Chinese poultry producers use an inactivated H5N1 disease under control.7
virus for vaccination of birds. However, the vaccination
does not confer complete immunity, which is evident Morphology and genetic structure of the virus
from the fact that the vaccinated birds may develop the
The morphology of influenza A (H5N1) is basically
disease possibly due to infection by new strains
that of an orthomyxovirus as it is a subtype of the type
resulting out of genetic reassortments, as is the case
A influenza virus. The typical virion is enveloped,
with H5N1 strain now sweeping Asia. According to
spherical (100 nm), with a nucleocapsid of helical
symmetry surrounding a minus sense single stranded 8
*Corresponding author segmented RNA (Figure). The envelope is internally
Department of Microbiology (SP, AM), Department of lined by a matrix protein (M) and externally with
General Surgery (PKP), Department of Pathology (SM), glycoprotein peplomers-rod shaped haemagglutinin
MKCG Medical College, Berhampur, Orissa - 760 004, (HA) which are homotrimers of class I membrane
India. glycoproteins and mushroom shaped neuraminidase
Received : 14-02-2004 (NA) molecules which are tetramers of a class II
Accepted : 14-04-2004 membrane protein.

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July, 2004 Padhi et al – Avian Influenza 144

through infected aerosols, discharges and surfaces, as

large amounts of the virus are excreted in bird droppings
and can survive for some time in the environment.

There is no evidence of human to human

transmission till date.3 Fortunately, these viruses lack the
ability to ‘hop’ easily between people, which has
probably helped to contain the problem. However, in the
future, a strain might acquire this ability, either by
mutation or by recombination of genetic material with a
human influenza virus and the ensuing virus would then
be highly pathogenic and transmissible causing an
“influenza pandemic”.8

Signs and symptoms

They are very similar to that of the disease caused

by other influenza viruses. Fever, malaise, myalgia, sore
throat and cough are found in most of the patients while
conjunctivitis is seen in some. Persistent high fever is
Figure: Schematic diagram of influenza A virus an useful sign. Life threatening complications like viral
pneumonia, respiratory distress syndrome and multi
HA - Haemagglutinin; NA - Neuraminidase; M(M1 & M2) - organ failure may result in the death of the patient.
Matrix protein; NS - Non-structural protein; NP -
Nucleoprotein; PA, PB1, PB2 - Polymerase proteins Diagnosis

A patient is suspected to be suffering from “avian

Based on the variation on HA and NA molecules
influenza” (‘bird flu’) if he/she has any respiratory illness
there exists 15 HA and 9 NA subtypes of influenza A
and has had recent direct or indirect contact by handling,
virus. The avian strains differ from human strains in that
or by having taken care, or by exposure to sick chickens
they have all the 15 subtypes of HA in contrast to only
or other birds. Besides the classical clinical presentations
three in case of humans.
as described above, X-ray of the chest is useful in
The virulent avian influenza H5N1 strains differ from detecting early viral pneumonia.
other avian strains in that, there lies a link between HA
Specimens like nasopharyngeal aspirate,
cleavage and degree of virulence. In virulent strains the
endotracheal aspirate, sputum and serum from clinically
HAs contain multiple basic aminoacids at the cleavage
suspected cases are subjected for laboratory
site, which are cleaved intracellularly by endogenous
investigations for further confirmation.
proteases. In contrast, in case of avirulent avian strains
as well as non-avian influenza A viruses, the HAs lack Laboratory Diagnosis
the basic aminoacid residues, hence not subjected to
cleavage by such proteases. Moreover, all types of Rapid antigen detection by immunofluorescence
influenza A viruses are antigenically labile, well adapted assay and enzyme immuno assay, virus isolation by
to evade host defences and lack mechanisms for “proof culture in HeP-2, RD cells or MDCK cell lines and
reading”; hence constant, permanent and small changes identification by immunofluorescence assay using
in antigenic composition are very common, which is specific monoclonal antibody and haemagglutination
known as antigenic drift. Another important inhibition assay have been used for diagnosis. 9
characteristic of great public health concern is antigenic Detection of influenza- specific RNA by reverse
shift which results from reassortment of genetic material transcriptase-polymerase chain reaction, by using primer
from different species resulting in variability of HA sets specific for HA sequence of influenza A/H5 and of
spikes, keeping the basic structure of the virus constant. N1 are some of the other tests that have been developed.
Serological identification by measuring the specific
Modes of transmission to humans antibodies by haemagglutination inhibition test, enzyme
immuno assay and the virus neutralisation test, more
The disease is transmitted to humans by direct or
specifically the micro neutralisation test, have also been
indirect contact with infected wild ducks and chickens
developed. Following kits are presently available:

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145 Indian Journal of Medical Microbiology Vol.22, No.3

1. Immunoflourescence assay- WHO influenza reagent shown resistance to amantadine and rimantadine, two
kit for the identification of Influenza A/H5 virus of the antiviral drugs commonly used for influenza.
(1997-1998, 2003 or 2004 version) which includes However, other antivirals (oseltamavir and zanamavir) are
influenza type A/H5- specific monoclonal antibody still effective against this strain of H5N1.6
pool along with influenza B, A/H1 and A/H3 subtype
specific monoclonal antibodies. Vaccine

2. Virus culture - Madin-Darby Canine Kidney cells At present there is no available human vaccine for
(MDCK). ATCC CCL34. avian flu and production of a new vaccine would not
begin until the disease shows “significant human-to-
• Inactivated virus, goat serum to A/Term/South human transmission”.5
Africa/61/H5, chicken pooled serum to A/
Goose/Hong Kong/437-4/99. Containment

• WHO influenza reagent kit: reference antigens The culling of sick and exposed birds is the key to
and reference antisera. containing the outbreak. For the current outbreak in Asia,
governments are culling poultry to try to contain the
• Receptor destroying enzyme (RDE).
virus. Patients are being treated and isolated and
• Red blood cells (chicken, turkey, human type O, investigations are under way to determine the source of
or guinea-pig red blood cells) in Alsever’s infection.
solution.
Prevention
3. Polymerase chain reaction - Gene primers from Hong
Kong, Government Virus Unit. The ban on importing of live chickens and other
poultry products from countries affected with ‘bird flu’
All laboratory results for influenza A/H5N1 should is a critical step to prevent the entry of ‘bird flu’ into
be confirmed by a WHO collaborating center for India. Other important steps to be followed are :
influenza or by another WHO- recommended reference
laboratory. The WHO reference laboratories are as • Wearing of masks and gloves by persons handling
below10: poultry.
• Cleaning kitchen surfaces and utensils before and
Queen Mary Hospital, University of Hong Kong. after use
National Influenza Center, Kowloon, Hong Kong. • Cooking chicken till boiling temperature is reached
National Institute of Infectious disease, Tokyo, Japan. • Controlling human traffic into poultries.
National Institute of Medical Research, UK. • Reporting to authorities any unusual death or illness
Department of Infectious disease, Memphis, USA. of chickens or other birds as well as illness of
Centers for Disease Control and Prevention, Atlanta, workers in poultry farms.
USA.
Conclusion
Treatment
Even after tremendous development in molecular
If ‘bird flu’ is suspected in a person, treatment biology, the mysteries surrounding the complex viral
should be started immediately without waiting for genetic reassortments giving rise to new pathogenic viral
laboratory confirmation. Treatment for infection by the mutants, remain unclear to the scientists till date. But
H5N1 strain is essentially similar to that employed for we can hope that, in future the virologists and
infections due to the other influenza viruses. biotechnologists will be able to unveil these secrets and
Unfortunately, the current strain of H5N1 has already save a number of precious human lives.

References
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Accessed February 9, 2004. 020819/020819_14.html. Accessed February 4, 2004.

2. Whitfield J. Deadly flu evades body’s defences. 3. China. Likely source of bird flu: New Scientist.
Nature news Service/Macmillan Magazines Ltd. Available at: http://www.economictimes.indiatimes.

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July, 2004 Padhi et al – Avian Influenza 146

com/articleshow/449636.cms. Accessed February 9, cases_table_2004_02_09/en/. Accessed February 9,

2004. 2004.
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5. Elegant S. Is a human pandemic next? Time 2004;
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A (H5N1). Available at : http://www.who.int/csr/
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L V Prasad Eye Institute

HYDERABAD, INDIA

Announcement

Applications are invited from candidates interested in making a career in Ocular Microbiology
at LV Prasad Eye Institute. The job encompasses all aspects of diagnostic work related to
eye infections/inflammations, in addition to ample scope for research and teaching. The
position is open to individuals trained in clinical (bacterial/fungal/viral/parasitic) microbiology,
molecular microbiology, microbial genetics etc.

Essential Qualifications : MBBS and MD (Medical Microbiology) or

PhD (Medical Microbiology)
Preferred added Qualifications : Experience in molecular techniques and virology
Desired Qualifications : Experience in ocular microbiology
Application Deadline : August 31, 2004
Age Limit : 35 years
Emoluments : To be fixed according to the salary structure
comparable to national centres, based on experience

Mail your CV with a letter of reference to the following address:

Prof. D. Balasubramanian
Director of Research
L V Prasad Eye Institute
L V Prasad Marg, Banjara Hills, Hyderabad – 500 034
Email : [email protected]

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