Acquisition of Human-Type Receptor Binding Specificity by New H5N1 Influenza Virus Sublineages during Their Emergence in Birds in Egypt

Abstract

Highly pathogenic avian influenza A virus subtype H5N1 is currently widespread in Asia, Europe, and Africa, with 60% mortality in humans. In particular, since 2009 Egypt has unexpectedly had the highest number of human cases of H5N1 virus infection, with more than 50% of the cases worldwide, but the basis for this high incidence has not been elucidated.

A change in receptor binding affinity of the viral hemagglutinin (HA) from α2,3- to α2,6-linked sialic acid (SA) is thought to be necessary for H5N1 virus to become pandemic.

In this study, we conducted a phylogenetic analysis of H5N1 viruses isolated between 2006 and 2009 in Egypt. The phylogenetic results showed that recent human isolates clustered disproportionally into several new H5 sublineages suggesting that their HAs have changed their receptor specificity. Using reverse genetics, we found that these H5 sublineages have acquired an enhanced binding affinity for α2,6 SA in combination with residual affinity for α2,3 SA, and identified the amino acid mutations that produced this new receptor specificity. Recombinant H5N1 viruses with a single mutation at HA residue 192 or a double mutation at HA residues 129 and 151 had increased attachment to and infectivity in the human lower respiratory tract but not in the larynx. These findings correlated with enhanced virulence of the mutant viruses in mice. Interestingly, these H5 viruses, with increased affinity to α2,6 SA, emerged during viral diversification in bird populations and subsequently spread to humans. Our findings suggested that emergence of new H5 sublineages with α2,6 SA specificity caused a subsequent increase in human H5N1 influenza virus infections in Egypt, and provided data for understanding the virus's pandemic potential.

Discussion
excerpt:
These findings suggest that currently circulating H5N1 viruses in Egypt lack gene products for efficient human-human transmission, even though they have caused a relatively large number of human cases in Egypt. Indeed, most human infections resulted from direct exposure to H5N1 virus-infected poultry or poultry products and no sustained human-human transmission has been documented to date in Egypt [1], [44]. It should be noted that our findings do not allow determination of the potential for an H5N1-derived pandemic virus in Egypt. However, the emergence of sublineage A and B H5N1 viruses is a possible contributing factor to Egypt recently having the highest number of human H5N1 influenza virus cases in the world, with repeated avian infections increasing the probability of avian-human transmission. To our knowledge, this is the first report identifying amino acid changes in H5 HA responsible for an increase in human H5N1 infections in an endemic area.