Influenza Teaching Current Update 2023 by Dr.T.V.Rao MD
Influenza Teaching Current Update 2023 by Dr.T.V.Rao MD
Influenza Teaching Current Update 2023 by Dr.T.V.Rao MD
INFLUENZA
CURRENT UPDATES
H3 N2
2023
Dr.T.V.Rao MD
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 2
WHAT IS H3 N2
• H3N2 is a non-human influenza
virus that normally circulates in
pigs and has infected humans,
according to the US Centre for
Disease Control and Prevention
(CDC). Symptoms are similar to
those of seasonal flu viruses
and can include fever and
respiratory symptoms such as
cough and runny nose, and
possibly other symptoms,
including body ache, nausea,
vomiting or diarrhoea.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 4
Mumps
Measles.
Newcastle disease
Parainluenza virus
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 6
Historically Speaking
• Influenza can be
traced as far back as
400 BC
• In Hippocrates’ Of
the Epidemics, he
describes a cough
outbreak that
occurred in 412 BC in
modern-day Turkey
at the turn of the
autumn season
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 7
INFLUENZA
• Cause of the
infection of the
Respiratory tract.
• Occurs as
Sporadic
Epidemic
Pandemic
Major pandemic
in 1918 – 1919
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 12
Scientific contributions
Spread of Influenza
• The virus is
transmitted easily
from person to
person via
droplets and
small particles
produced when
infected people
cough or sneeze.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 15
H 1-16
Domestic pig
N 1-9
Domestic birds
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 17
Structure of Virion
HA - hemagglutinin
NA - neuraminidase
polymerase complex
Influenza virions are SMALL. The average eukaryotic cell diameter is 10,000 nm
(10 microns), which is 100 times bigger than the influenza virion diameter.
M1 protein http://www.med.sc.edu:85/pptvir2002/INFLUENZA-2002.ppt
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 22
Influenza Virus
• Virus are
spherical in
shape
• Size is 80 -120
nm
• Pleomorphism is
common with
variant forms
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 23
Viral structure
A negative
sense Single
stranded
RNA
genome is
segmented
into 8
segments
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 24
Viral structure
• The nucelocapsid is
surrounded by an
envelope with inner
membrane protein
layer and outer lipid
• From the envelop
there are projections of
two types
• 1 Hem agglutinins
• 2 Neuraminidase
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 25
Resistance of Virus
• Inactivated by heating at 500c for 30
mt
• Survive for 1 week at 0 – 40c for 1
week
• Virus preserved at – 700c
• Survive in the blankets for 2 weeks
• Ether, formaldehyde, Phenol destroy
the virus
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 26
HN terminology
• H refers to Haemagglutinnins types
and each is given a number H1, H2
etc,
• Neuraminidase is designated N and
different forms are available as well
e.g. H5N1 (avian) and H1N1.
• Different combinations of H and N
glycoproteins give rise to different
strains
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 29
Haemagglutination
• Act with red cells of
different species
• Type A and B – RBC’s of Fowl, Human and
guinea pigs
• Type C only RBC’s of Fowl at 40c
• Haemagglutination titer - Highest titer of virus
with fixed quantity of RBC
• Haemagglutination Inhibition titers convenient
way of measuring quantity o antibodies to
virus.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 30
Types of Haemagglutinnins
• Haemagglutination is
strain specific
• Great variation
• H A there are 15
subtypes H 1 to H15
in avian influenza
• But only 4 variants in
humans
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 31
Neuraminidases
• Neuraminidase are glycoprotein's
• Destroys cell receptors by hydrolysis cleavage
• Anti neuraminidase antibodies are produced
following infection and immunization
• Not protective as Antihemagglutinin antibodies
• Helps to inhibit the release and spread of
progeny
• Strain specific exhibit variation, There are nine
different subtypes N 1 – N9.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 32
Antigenic Variation
Antigenic Variations
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 36
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 37
Antigenic Shift
• It is abrupt and Drastic
• Discontinuous variation
in structure in antigens
• Results in novel virus
and unrelated to
previous strains causing
infections
• Involves –
Haemagglutinnins,
Neuraminidase or both
• Subtypes depends only
on antigenic shifts,
occurs on
Haemagglutinnins
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 38
Terminology by WHO
• Ao A1 A2 ( Asian ) A2 ( H K )
• Ho H1 H2 H3
Host Range
• Experimented in Animals
• Spread through respiratory shredding
• Respiratory disease in Ferrets
• Intranasal passage in Mice
• Infect the amniotic cavity of Allantois
and Amniotic fluids
• Virus can be grown in primary
monkey kidney and in continuous cell
lines
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 41
Pathogenesis
• Infects the respiratory tract
• Even 3 or few viral particles can infect
• Neuraminidase facilitates infection reducing
the viscosity of Mucous
• Ciliated cells are infected in the Respiratory
tract - site of viral infection
• When superficial layers are damaged
exposes the basal layers
• And exposure of the basal layer causes the
bacterial infections.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 43
Reservoirs of Virus
• Virus harbored as
Asymptomatic infection
• All isolates from Non
human hosts harbor
type A virus
• Types B and C are
exclusively common to
Humans, Not identified
in animals or birds
• Plays a great role in
emerging pandemics
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 44
TRANSMISSION
• AEROSOL
• 100,000 TO 1,000,000
VIRIONS PER
DROPLET
• 18-72 HR
INCUBATION
• SHEDDING
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 45
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 46
Clinical features
• Incubation 1 to 3 days
• Present with mild cold lead to
fulminating rapidly fatal Pneumonia
• Can abruptly present with head ache
malign
• Can also present with abdominal pain
with type B in children
• Bacteria superinfect
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 48
SYMPTOMS
• FEVER
• HEADACHE
• MYALGIA
• COUGH
• RHINITIS
• OCULAR SYMPTOMS
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 49
CLINICAL FINDINGS
• SEVERITY
• VERY YOUNG
• ELDERLY
• IMMUNO-
COMPROMISED
• HEART OR
LUNG DISEASE
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 50
Complications of Influenza
• Bacterial super infections
• Cardiac complications
• Congestive heart failure
• Myocarditis
• Neurological involvement
• Encephalitis
• Type B virus can produce Reye’s syndrome
• Degenerative changes in the Brain and Liver
• Gastric flu with type B virus
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 51
Complications in Influenza
• Pneumonia
• secondary bacterial
• primary influenza viral
• Reye’s syndrome
• Myocarditis
• Death 0.5-1 per 1,000 cases
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 53
Immunity in Influenza
• After infection immunity
lasts 1 to 2 years
• Immunity lasts short
duration due antigenic
variants infecting at
intervals.
• Antibodies produced
locally are effective IgA
immunoglobulin.
• Anti Hemagglutinins and
Antinerumanidase are
effective in prevention of
infection.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 54
Epidemiology
• Virus enters through respiratory route
• In 3 – 4 days majority manifest
• Many are subclinical infections
• Type A produce pandemics
• Type B sporadic cases, epidemics
• Dangerous in the Temperate regions
• Higher mortality in aged and patients with
existing cardiopulmonary involvement
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 55
RECENT MAJOR
PANDEMICS
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 56
BIRD FLU
• Birds, just like
people, get the flu.
Bird flu viruses
infect birds,
including chickens,
other poultry and
wild birds such as
ducks. Most bird flu
viruses can only
infect other birds.
However, bird flu
can pose health
risks to people.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 60
Influenza Diagnosis
• Clinical and
epidemiological
characteristics
• Isolation of influenza
virus from clinical
specimen (e.g.,
nasopharynx, throat,
sputum)
• Significant rise in
influenza IgG by
serologic assay
• Direct antigen testing
for type A virus
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 63
Isolation of Virus
• In the first 2 -3 days from gargle samples
• Specimens inoculated into eggs, and Monkey kidney
cells.
• Eggs are inoculated into Amniotic and Allantoic cavity
Grows at 370 C in 3 days
• The virus causes Haemagglutination of Guinea pig
and Fowl erythrocytes at 370 C
• Type A and B agglutinate guinea pig and fowl red cells
• Type C Hem agglutinates only Fowl cells
• Cytopathic effects on Monkey Kidney and Continuous
cell lines
• RNA detection by RT – PCR
• Immuno florescence – surface of Nasopharyngeal
cells
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 65
Serology
• Compliment fixation
test
• Haemagglutination
Inhibition testing
• Testing on paired
sera
• Detection of
Haemagglutination
Inhibition testing
• Radial
Immunodiffusion
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 66
(Injectable
Peramivir has
completed
phase-1 trials)
Tamiflu!
(oral)
Ralenza
(inhaled)
(Older
drugs)
(Viral resistance to these is more common)
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 73
Chemotherapy
• Tamiflu (oseltamivir) – inhibits the
neuraminidase and thus prevents the
spread of the virus in the body
• Tamiflu can therefore be used to
reduce the length of illness and its
transmission within a household
• Resistance of H1N1 strain to
oseltamivir has been reported at 25%
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 74
Prevention
• WHO monitors the
events on Influenza
• Identifies the
subtypes circulating
all over the world.
• Vaccine
Cocktail vaccine
contains one or
two types of A and
type B virus of the
previous winter
months.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 75
Influenza Vaccines
• Inactivated subunit
(TIV) vaccine
• intramuscular
• trivalent
• split virus and subunit
types
• duration of immunity 1
year or less
• Live attenuated
vaccine (LAIV)
• intranasal
• trivalent
• duration of immunity at
least 1 year
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 76
Influenza Vaccine
Recommendations
• Healthcare
providers,
including home
care*
• Employees of long-
term care facilities
• Household contacts
of*LAIV
high-risk persons
should not be administered to healthcare workers who have
contact with severely immunosuppressed persons who require
hospitalization and care in a protective environment
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 77
• A live
attenuated Cold
adopted
temperature
sensitive used
as nasal spray
on major trails.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 80
• Covering your
nose and mouth
with a tissue
when you cough
or sneeze.
Throw the tissue
in the trash after
you use
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 83
• Washing your
hands often with
soap and water,
especially after
you cough or
sneeze. You can
also use alcohol-
based hand
cleaners.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 84
UPDATES ON H3 N2
2023
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 86
Chills
Coughing
Fever
Nausea
Vomiting
Throat ache/sore throat
An ache in muscles and body
In some cases, diarrhoea
Sneezing and runny nose
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 88
Diagnosis
• Laboratory tests are required to diagnose human
infection with zoonotic influenza. WHO, through its
Global Influenza Surveillance and Response System
(GISRS), periodically updates technical guidance
protocols for the detection of zoonotic influenza in
humans using molecular e.g. RT-PCR and others
methods.
Treatment Guidelines
As per suggestions of WHO
Evidence suggests that
some antiviral drugs,
notably neuraminidase
inhibitor (oseltamivir,
zanamivir), can reduce
the duration of viral
replication and improve
prospects of survival,
however ongoing clinical
studies are needed.
Emergence of oseltamivir
resistance has been
reported.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 91
Treatment Guidelines
As per suggestions of WHO
• In suspected and confirmed cases, neuraminidase
inhibitors should be prescribed as soon as possible
(ideally, within 48 hours following symptom onset) to
maximize therapeutic benefits. However, given the
significant mortality currently associated with A(H5)
and A(H7N9) subtype virus infections and evidence of
prolonged viral replication in these diseases,
administration of the drug should also be considered
in patients presenting later in the course of illness.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 92
PREVENTION
As per suggestions of WHO
• Apart from antiviral treatment, the public health
management includes personal protective
measures like:
Regular hand washing with proper drying of the
hands
• Good respiratory hygiene – covering mouth and
nose when coughing or sneezing, using tissues
and disposing of them correctly
• Early self-isolation of those feeling unwell,
feverish and having other symptoms of influenza
• Avoiding close contact with sick people
• Avoiding touching one’s eyes, nose or mouth
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 94
Programs Today
Influenza program focuses on three main areas:
strengthening the Influenza Surveillance Network,
public health research, and pandemic
preparedness. CDC collaborations with GOI
partners aim to increase capacity of influenza
sentinel surveillance sites and laboratory services
for the timely detection and characterization of
respiratory viruses with pandemic potential. The
public health research helps assess influenza
burden (e.g., hospitalizations, mortality, and
estimated cost) and informs critical preventive and
control measures through improved
understanding of the epidemiology of respiratory
pathogens.
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 98
Major References
• WHO current issues on Influenza
• CDC Literature on facts, and prevention
• Open resources from Google
• National Institute on Health USA
• Public information resources
3/12/2023 Dr.T.V.Rao MD @ Current updates on H3 N2 Influenza 99
• doctortvrao@gmail.com