1. Clinical Outcomes of Influenza Infection Asymptomatic Asymptomatic Symptomatic Symptomatic  Respiratory syndrome - mild to severe  Involvement of major organs - brain, heart, etc. heart, etc.  Death

2. Factors Influencing the Response to Influenza Age Age Pre-existing immunity (some crossover) Pre-existing immunity (some crossover) Smoking Smoking Concurrent other health conditions Concurrent other health conditions Immunosuppression Immunosuppression Pregnancy Pregnancy

3. Virology of Influenza Subtypes: A - Causes outbreak B - Causes outbreaks C - Does not cause outbreaks

4. Immunogenic Components of the Influenza Virus Surface glycoproteins, 15 hemagglutinins (H 1 - H 15 ), nine neurominidases (N 1 -N 9 ) Surface glycoproteins, 15 hemagglutinins (H 1 - H 15 ), nine neurominidases (N 1 -N 9 ) H 1 -H 3 and N 1 N 2 established in humans H 1 -H 3 and N 1 N 2 established in humans Influenza characterized by combination of H and N glycoproteins Influenza characterized by combination of H and N glycoproteins  1912 pandemic - H 1 N 1  2004 avian influenza - H 5 N 1 Antigenic mix determines severity of disease Antigenic mix determines severity of disease Human response specific to hemagglutinin and neurominidase glycoproteins Human response specific to hemagglutinin and neurominidase glycoproteins

5. Spread of H 5 N 1 Avian Influenza 12 14 16 18 20 22 24 26 28 30 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 2 December, 2003 January 2004 Feb December, 2003 January 2004 Feb South Korea Vietnam Japan Thailand Cambodia China & Laos Indonesia

6. Figure 1. Natural hosts of influenza viruses Nicholson et al. Influenza. Lancet 362:1734, 2003

7. Nicholson et al. Influenza. Lancet 362:1735, 2003 Figure 2. Origin of antigenic shift and pandemic influenza. The segmented nature of the influenza A genome, which has eight genes, facilitates reassortment; up to 256 gene combinations are possible during coinfection with human and non-human viruses. Antigenic shift can arise when genes encoding at least the haemagglutinin surface glycoprotein are introduced into people, by direct transmission of an avian virus from birds, as occurred with H5N1 virus, or after genetic reassortment in pigs, which support the growth of both avian and human viruses.

8. Outbreaks of Avian Influenza A (H5N1)... MMWR 53(5):102, 2004

9. Intervention Strategies Culling (killing of infected flocks) Culling (killing of infected flocks) Innovative surveillance strategies -Identification and analysis of human to human clusters -Necessary for vaccine development (Science 304:968-9, 5/2004) Vaccination of bird handlers (vaccine being developed) Vaccination of bird handlers (vaccine being developed)