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Respiratory Viruses An Overview
Viruses Associated with Respiratory Infections Syndrome Commonly Associated Viruses Less Commonly Associated Viruses Corza Rhinoviruses, Coronaviruses Influenza and parainfluenza viruses, enteroviruses, adenoviruses Influenza Influenza viruses Parainfluenza viruses, adenoviruses Croup Parainfluenza viruses Influenza virus, RSV, adenoviruses Bronchiolitis RSV Influenza and parainfluenza viruses, adenoviruses Bronchopneumonia Influenza virus, RSV, Adenoviruses Parainfluenza viruses, measles, VZV, CMV
Influenza Virus (Courtesy of Linda Stannard, University of Cape Town, S.A.) RNA virus, genome consists of 8 segments enveloped virus, with haemagglutinin and neuraminidase spikes 3 types: A, B, and C Type A undergoes antigenic shift and drift. Type B undergoes antigenic drift only and type C is relatively stable
Influenza A Virus Undergoes antigenic shifts and antigenic drifts with the haemagglutinin and neuraminidase proteins. Antigenic shifts of the haemagglutinin results in pandemics. Antigenic drifts in the H and N proteins result in epidemics. Usually causes a mild febrile illness. Death may result from complications such as viral/bacterial pneumonia.
Epidemiology Pandemics - influenza A pandemics arise when a virus with a new haemagglutinin subtype emerges as a result of antigenic shift. As a result, the population has no immunity against the new strain. Antigenic shifts had occurred 3 times in the 20th century. Epidemics - epidemics of influenza A and B arise through more minor antigenic drifts as a result of mutation.
Past Antigenic Shifts 1918 H1N1 “Spanish Influenza” deaths 20-40 million 1957 H2N2 “Asian Flu” 1-2 million deaths 1968 H3N2 “Hong Kong Flu” 700,000 deaths 1977 2009 H1N1 Re-emergence H1N1 “Swine Flu No pandemic Mild Pandemic At least 15 HA subtypes and 9 NA subtypes occur in nature. Up until 1997, only viruses of H1, H2, and H3 are known to infect and cause disease in humans.
Avian Influenza - 1 H5N1 An outbreak of Avian Influenza H5N1 occurred in Hong Kong in 1997 where 18 persons were infected of which 6 died. The source of the virus was probably from infected chickens and the outbreak was eventually controlled by a mass slaughter of chickens in the territory. All strains of the infecting virus were totally avian in origin and there was no evidence of reassortment. However, the strains involved were highly virulent for their natural avian hosts. Since 2003, human cases of H5N1 have been reported in a number of Asian and African countries. The WHO has put great priority and resources in the surveillance of H5N1 infections worldwide in the hope of averting or diminishing the impact of a pandemic.
Avian Influenza - 2 H9N2 Several cases of human infection with avian H9N2 virus occurred in Hong Kong and Southern China in 1999. The disease was mild and all patients made a complete recovery. Again, there was no evidence of reassortment. H7N9 Human infection by H7N9 virus was first reported in China in 2013. Since then, there had been outbreaks every year in China. Most of the cases of human infection with this avian H7N9 virus have reported recent exposure to live poultry or potentially contaminated environments. Most infected patients have become severely ill with a high mortality rate (up to 25%) This virus does not appear to transmit easily from person to person.
Theories Behind Antigenic Shift 1. Reassortment - Reassortment of the H and N genes between human and avian influenza viruses through a third host. There is good evidence that this occurred in the 1957 H2N2 and the 1968 H3N2 pandemics. The 2009 pandemic virus was thought to be novel virus that was a triple re-assortant involving human, bird, N. American pig and Eurasian pig viruses. 2. Recycling of pre-existing strains – this probably occurred in 1977 when H1N1 re-surfaced. 3. Gradual adaptation of avian influenza viruses to human transmission. There is some evidence that this occurred in the 1918 H1N1 pandemic.
Reassortment A v i a n H 3 H u m a n H 2 H u m a n H 3
Laboratory Diagnosis Rapid Diagnosis – nasopharyngeal aspirates, throat and nasal swabs are normally used. Antigen Detection – can be done by IFT or EIA RNA Detection – RT-PCR assays give the best sensitivity and specificity. It is the only method that can differentiate the 2009 pandemic H1N1 strain from the seasonal H1N1 strain. However, it is expensive and technically demanding. Virus Isolation - virus may be readily isolated from nasopharyngeal aspirates and throat swabs. Serology - a retrospective diagnosis may be made by serology. CFT most widely used. HAI and EIA may be used to give a type-specific diagnosis
Management Neuraminidase inhibitors - are now the drugs of choice. They are highly effective and have fewer side effects than amantidine. Oseltamivir (Tamiflu) is the most commonly used agent as it can be given orally unlike Zanamivir (Relenza) and Peramivir (Rapivab). The resistance to different types varies enormously year to year. H3N2 strains were mainly sensitive whereas seasonal H1N1 were almost totally resistant. More than 98% of the 2009 pandemic influenza H1N1 tested were sensitive. . Amantidine is effective against influenza A if given early in the illness. However, resistance to amantidine emerges rapidly. Rimantidine is similar to amantidine but but fewer neurological side effects. Ribavirin is thought to be effective against both influenza A and B.
Prevention Inactivated split/subunit vaccines are available against influenza A and B. The vaccine is normally trivalent, consisting of one A H3N2 strain, one A H1N1 strain, and one B strain. The strains used are reviewed by the WHO each year. The vaccine should be given to debilitated and elderly individuals who are at risk of severe influenza infection. Oseltamivir can be used as an prophylaxis for those who are allergic to the vaccine or during the period before the vaccine takes effect.
Parainfluenza Virus (Linda Stannard, University of Cape Town, S.A.) ssRNA virus enveloped, pleomorphic morphology 5 serotypes: 1, 2, 3, 4a and 4b No common group antigen Closely related to Mumps virus
Clinical Manifestations Croup (laryngotraheobroncitis) - most common manifestation of parainfluenza virus infection. However other viruses may induce croup e.g. influenza and RSV. Other conditions that may be caused by parainfluenza viruses include Bronchiolitis, Pneumonia, Flu-like tracheobronchitis, and Corza-like illnesses.
Laboratory Diagnosis Detection of Antigen - a rapid diagnosis can be made by the detection of parainfluenza antigen from nasopharyngeal aspirates and throat washings. RT-PCR - a number of RT-PCR assays had been developed, including multiplex assays for the detection of other respiratory viruses at the same time. RT-PCR - a number of RT-PCR assays had been developed, including multiplex assays for the detection of other respiratory viruses at the same time. Virus Isolation - virus may be readily isolated from nasopharyngeal aspirates and throat swabs. Serology - a retrospective diagnosis may be made by serology. CFT most widely used.
Management No specific antiviral chemotherapy available. Severe cases of croup should be admitted to hospital and placed in oxygen tents. No vaccine is available.
Respiratory Syncytial Virus (RSV) ssRNA eveloped virus. belong to the genus Pneumovirus of the Paramyxovirus family. Considerable strain variation exists, may be classified into subgroups A and B by monoclonal sera. Both subgroups circulate in the community at any one time. Causes a sizable epidemic each year.
Clinical Manifestations Most common cause of severe lower respiratory tract disease in infants, responsible for 50-90% of Bronchiolitis and 5-40% of Bronchopneumonia Other manifestations include croup (10% of all cases). In older children and adults, the symptoms are much milder: it may cause a corza-like illness or bronchitis.
Infants at Risk of Severe Infection 1. Infants with congenital heart disease - infants who were hospitalized within the first few days of life with congenital disease are particularly at risk. 2. Infants with underlying pulmonary disease - infants with underlying pulmonary disease, especially bronchopulmonary dysplasia, are at risk of developing prolonged infection with RSV. 3. Immunocompromized infants - children who are immunosuppressed or have a congenital immunodeficiency disease may develop lower respiratory tract disease at any age.
Laboratory Diagnosis Detection of Antigen - a rapid diagnosis can be made by the detection of RSV antigen from nasopharyngeal aspirates. A rapid diagnosis is important because of the availability of therapy RT-PCR - a number of RT-PCR assays had been developed, including multiplex assays for the detection of other respiratory viruses at the same time. Virus Isolation - virus may be readily isolated from nasopharyngeal aspirates. However, this will take several days. Serology - a retrospective diagnosis may be made by serology. CFT most widely used.
Treatment and Prevention Aerosolised ribavirin can be used for infants with severe infection, and for those at risk of severe disease. There is no vaccine available. RSV immunoglobulin can be used to protect infants at risk of severe RSV disease.
Adenovirus (Linda Stannard, University of Cape Town, S.A.) ds DNA virus non-enveloped At least 47 serotypes are known classified into 6 subgenera: A to F
Clinical Syndromes 1. Pharyngitis 1, 2, 3, 5, 7 2. Pharyngoconjunctival fever 3, 7 3. Acute respiratory disease of recruits 4, 7, 14, 21 4. Pneumonia 1, 2, 3, 7 5. Follicular conjunctivitis 3, 4, 11 6. Epidemic keratoconjunctivitis 8, 19, 37 7. Pertussis-like syndrome 5 8. Acute haemorrhaghic cystitis 11, 21 9. Acute infantile gastroenteritis 40, 41 10.Intussusception 1, 2, 5 11.Severe disease in AIDS and other immunocompromized patients 5, 34, 35 12. Meningitis 3, 7
Laboratory Diagnosis Detection of Antigen - a rapid diagnosis can be made by the detection of adenovirus antigen from nasopharyngeal aspirates and throat washings. PCR - a number of PCR assays had been developed, including multiplex assays for the detection of other respiratory viruses at the same time. Virus Isolation - virus may be readily isolated from nasopharyngeal aspirates, throat swabs, and faeces. Serology - a retrospective diagnosis may be made by serology. CFT most widely used.
Treatment and Prevention There is no specific antiviral therapy. A vaccine is available against Adult Respiratory Distress Syndrome. It consists live adenovirus 4, 7, and 21 in enterically coated capsules. It is given to new recruits into various arm forces around the world.
Common Cold Viruses Common colds account for one-third to one-half of all acute respiratory infections in humans. Rhinoviruses are responsible for 30-50% of common colds, coronaviruses 10-30%. The rest are due to adenoviruses, enteroviruses, RSV, influenza, and parainfluenza viruses, which may cause symptoms indistinguishable to those of rhinoviruses and coronaviruses.
Rhinovirus Reconstructed Image of rhinovirus particle (Institute for Molecular Virology) ssRNA virus Belong to the picornavirus family ssRNA virus acid-labile at least 100 serotypes are known
Coronavirus ssRNA Virus Enveloped, pleomorphic morphology 2 serogroups: OC43 and 229E The viruses responsible for SARS and MERS possibly have bats as their primary host, and civet cats and camels as secondary hosts.