Influenza

I

Introduction

Influenza, also known as flu, contagious infection primarily of the respiratory tract. Influenza is sometimes referred to as grippe. Influenza is caused by a virus transmitted from one person to another in droplets coughed or sneezed into the air. It is characterized by coldlike symptoms plus chills, fever, headaches, muscle aches, and fatigue. Most people recover completely in about a week. But some people are vulnerable to complications such as bronchitis and pneumonia. This group includes children with asthma, people with heart or lung disease, and the elderly. In the United States, people age 65 and older account for about 90 percent of influenza-associated deaths.

In addition to humans, influenza occurs in pigs, horses, and several other mammals as well as in certain wild and domesticated birds. At least some influenza viruses can jump from one species to another. For example, in late 1997 a strain of the influenza virus in chickens began to infect humans in Hong Kong, leading to a massive effort to eradicate the strain. See also Avian Flu.

Because influenza is highly contagious and spreads easily, it usually appears as epidemics—that is, outbreaks involving many people. If an outbreak spreads around the world—not uncommon in this age of rapid international travel—it is called a pandemic.

Many millions of people develop the flu each year. In most years less than 1 percent of those infected die. Nonetheless, this translates into large numbers. The United States Centers for Disease Control and Prevention (CDC) estimates that influenza causes more than 20,000 deaths in the United States each year; combined, influenza and pneumonia are among the nation’s ten leading causes of death. During epidemics and pandemics, death rates soar. The influenza pandemic that occurred from 1918 to 1919—the worst on record—killed about 500,000 people in the United States and from 20 million to 50 million people worldwide.

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II

Cause

The word influenza is derived from the Latin word influentia. Italians in the early 16th century first applied the word influenza to outbreaks of any epidemic disease because they blamed such outbreaks on the influence of heavenly bodies. The first known use of the name specifically for the flu occurred in 1743 when an epidemic swept through Rome and its environs.

Today scientists know that members of the family Orthomyxoviridae, a group of viruses that infect vertebrate animals, cause influenza. The virus consists of an inner core of the genetic material ribonucleic acid (RNA) surrounded by a protein coat and an outer lipid (fatty) envelope. From this envelope, spikes of proteins called hemagglutinin and neuraminidase stick out. Hemagglutinin enables the virus to bind to and invade cells, and neuraminidase allows the virus to move among cells. But these proteins also act as antigens—that is, they are recognized as foreign matter by the human or other host organism, and this recognition triggers an immune response in the host.

There are three types of influenza viruses, known as A, B, and C. Type A, the most dangerous, infects a wide variety of mammals and birds. It causes the most cases of the disease in humans and is the type most likely to become epidemic. Type B infects humans and birds, producing a milder disease that can also cause epidemics. Type C apparently infects only humans. It typically produces either a very mild illness indistinguishable from a common cold or no symptoms at all. Type C does not cause epidemics.

Influenza type A and B viruses continually change. Some changes involve a series of genetic mutations that, over a period of time, cause a gradual evolution of the virus. Called antigenic drift, this process accounts for most of the changes in influenza viruses that occur from one year to the next. Other changes, less common but more injurious, involve abrupt changes in the hemagglutinin or neuraminidase. This type of change is called antigenic shift and results in a new subtype of the virus. Type A viruses undergo both kinds of transformations; influenza type B viruses apparently change only by the process of antigenic drift.

Scientists further differentiate virus subtypes into strains, generally named for the geographic area where they were first detected. For example, the strains that caused the most infections during the 2001-2002 flu season in the Northern Hemisphere were type A New Caledonia and Moscow strains and Type B Sichuan strain.

Once a person has been infected by a specific strain of influenza, he or she has built up immunity to that strain in the form of antibodies. The person’s immune system then can recognize the strain’s hemagglutinin or neuraminidase and attack them if they reappear. The antibodies offer some protection against antigenic drifts, but not against antigenic shifts. Thus, because the viruses continually change, they can cause repeated waves of infection, even among people previously infected.

Scientists do not understand exactly what causes antigenic shifts. One leading theory suggests that a human strain and an animal strain recombine to create a new strain. This strain has the ability to infect humans but has antigens on its surface that are unfamiliar to the human immune system.

III

Transmission

Influenza viruses pass from person to person mainly in droplets expelled during sneezes and coughs. When a person breathes in virus-laden droplets, the hemagglutinin on the surface of the virus binds to enzymes in the mucous membranes that line the respiratory tract. The enzymes, known as proteases, cut the hemagglutinin in two, which enables the virus to gain entry into cells and begin to multiply. These proteases are common in the respiratory and digestive tracts but not elsewhere, which is why the flu causes primarily a respiratory illness with occasional gastrointestinal symptoms. In the 1990s scientists discovered that some flu strains also can use the enzyme plasmin to cut hemagglutinin. Plasmin is common throughout the body, enabling the flu strains to infect a variety of tissues.

Although an influenza epidemic can occur at any time of year, flu season in temperate regions typically begins with the approach of winter—November in the Northern Hemisphere, April in the Southern Hemisphere. Flu viruses spread more easily during cold weather. An influenza epidemic may be restricted to a town or city or may quickly spread geographically as infected people travel.

Scientists long thought that the flu season occurred in winter because that is when people tend to spend more time crowded together in homes and schools, as well as in buses, subways, and other places with poor ventilation. A study on guinea pigs, reported in 2007, found that transmission of the virus depends upon temperature and humidity. Transmission among the guinea pigs declined as the temperature rose above 5°C (41°F) and stopped completely at 30°C (86°F). Low humidity favors transmission of the virus. The scientists who conducted the study believe the flu virus is most stable at low temperatures and in dry air, conditions prevalent in winter.

IV

Symptoms and Diagnosis

Influenza is an acute disease with a rapid onset and pronounced symptoms. After the influenza virus invades a person’s body, an incubation period of one to two days passes before symptoms appear. Classic symptoms include sore throat, dry cough, stuffed or runny nose, chills, fever with temperatures as high as 39ºC (103ºF), aching muscles and joints, headache, loss of appetite, occasional nausea and vomiting, and fatigue. For most people flu symptoms begin to subside after two to three days and disappear in seven to ten days. However, coughing and fatigue may persist for two or more weeks.

Death from influenza itself is rare. But influenza can aggravate underlying medical conditions, such as heart or lung disease. Invading influenza viruses produce inflammation in the lining of the respiratory tract, damage that increases the risk that secondary infections will develop. Common complications include bronchitis, sinusitis, and bacterial pneumonia, occurring most frequently in older people, people on chemotherapy, and people with acquired immunodeficiency syndrome (AIDS) or other diseases that compromise the immune system. If properly treated, these complications seldom are fatal.

Because influenza is so common and exhibits standard symptoms, doctors often diagnose the illness based on the season and whether flu cases have recently been reported in the area. To prove a diagnosis of influenza in a patient, the virus must be isolated from the person’s nasal or cough secretions or blood and identified under a microscope.

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