Human infections with influenza H5N1 virus: How many?

The lethality of avian influenza H5N1 infections in humans has been a matter of extensive debate. The >50% case fatality rate established by WHO is high, but the lethality of the virus might be lower if there are many infections accompanied by mild or no disease. One way to answer this question is to determine how many individuals carry antibodies to the virus in populations that are at risk for infection. A number of such studies have been done, and some have concluded that the results imply a low but substantial level of infection (even less than one percent of millions of people is a lot of infections). The conclusion of a new meta-analysis of H5N1 serosurveys is that most of the studies are flawed, and that the frequency of H5 infections appears to be low.

Twenty-nine different H5N1 serological studies were included in this meta-analysis. None of these are particularly satisfactory according to the authors:

None of the 29 serostudies included what we would consider to be optimal, blinded unexposed controls in their published methodologies, i.e., including in the serology runs blinded samples from individuals with essentially no chance of H5N1 infection. Serological assays can easily produce misleading results, especially when paired sera are not available.

Some of the problems identified in the serological surveys include the possibility that many H5N1 positive sera are the result of false positives, that is, cross reaction with antigens from other influenza virus strains. In addition, many studies utilized H5N1 strains that are no longer circulating.

It is clear that most of the H5N1 serosurveys have not been done as well as they should have been. The authors conclude that “it is essential that future serological studies adhere to WHO criteria and include unexposed control groups in their laboratory assays to limit the likelihood of misinterpreting false positive results.”

Let’s not forget that a completely different way of assessing H5N1 infection – by looking for virus-specific T cells – has been reported. The results provide further evidence for subclinical H5N1 infection and are not subject to the caveats noted here for antibody surveys.

I come away from this meta-analysis with an uneasy sense that the authors are not being sufficiently objective, and that they firmly believe that there are no mild or asymptomatic H5N1 infections. One reason is the authors’ use of ‘only’ to describe their findings. For example: “Of studies that used WHO criteria, only [italics mine] 4 found any seropositive results to clades/genotypes of H5N1 that are currently circulating”. The use of ‘only’ in this context implies a judgement, rather than an objective statement of fact. Furthermore, despite the authors stated problems with all H5N1 serosurveys, they nonetheless conclude that there is little evidence for asymptomatic H5N1 infection. If the studies are flawed, how can this conclusion be drawn?

My concern about the authors’ objectivity is further heightened by the fact that they are members of the Center for Biosecurity at the University of Pittsburgh. These are individuals whose job it is to find dangerous viruses that could be used as weapons. On the front page of the website for the Center for Biosecurity is a summary of the meta-analyis article which concludes that “In the article, Assessment of Serosurveys for H5N1, Eric Toner and colleagues discuss their extensive review of past studies and conclude that there is little evidence to suggest that the 60% rate is too high.”

I would argue that if the H5N1 serosurveys are flawed, then do them properly; it is incorrect to simply assume that the H5N1 virus is as lethal as WHO suggests. The World Health Organization should call for and coordinate a study that satisfies criteria established by virologists and epidemiologists for a robust analysis of human H5N1 exposure.

How lethal is rabies virus?

Desmodus rotundusWhen I am asked to name the most lethal human virus, I never hesitate to name rabies virus. Infection with this virus is almost invariably fatal; just three unvaccinated individuals have been known to survive. New evidence from humans in the Peruvian Amazon suggests that the virus might be less lethal than previously believed.

Rabies virus is typically transmitted to humans by the bite of an infected mammal, often a carnivore or a bat. Recently there have been numerous outbreaks of rabies in Peru that have been linked to bites of vampire bats. A study of two communities at risk for vampire bat bites was undertaken to determine whether subclinical infection with rabies virus might occur. Over half of 92 individuals interviewed reported having been bitten by bats. Neutralizing antibodies against rabies virus were detected in 7 of 63 serum samples obtained from this population. Antibodies against the viral nucleoprotein were found in three individuals, two of whom were also positive for viral neutralizing antibodies. All 9 seropositive individuals indicated that they had previously had contact with a bat (a bite, scratch, or direct contact with unprotected skin). One of these individuals had previously received rabies vaccine.

The finding of neutralizing antibodies against rabies virus suggests that these individuals were likely infected, but did not develop fatal disease. It is also possible that they received a sufficiently large dose of virus to induce antibodies, but that viral replication did not occur. Another explanation for the findings is that these individuals were infected with an unknown virus that is highly related to rabies virus, but which is not pathogenic for humans.

There have been numerous seroprevalence studies of rabies infection in wildlife. For example, foxes and other canids have low (0-5%) seroprevalence rates, while 5-50% of bats can harbor rabies neutralizing antibodies, indicating that these animals are less susceptible to fatal rabies. In contrast, there have been few studies on rabies seroprevalence in humans. In one study of 30 raccoon hunters in Florida, low levels of rabies virus neutralizing antibodies were found in 2 samples. Low neutralizing antibody titers were also detected in 9 of 31 Canadian Inuit hunters; in a separate study, high rabies antibody titers were detected in the serum of 1 of 26 Alaskan fox trappers. All of these individuals had not been immunized with rabies virus vaccine.

Rabies virus causes 55,000 human deaths each year, so even if the results of the Peruvian study indicate subclinical infection, they would have little impact on the nearly 100% fatality rate associated with infection. More extensive studies are needed to determine if nonfatal human rabies infection is more common than believed. Understanding why some individuals do not die after infection might reveal immunological and genetic factors that protect against the disease.

Amy T. Gilbert, Brett W. Petersen, Sergio Recuenco, Michael Niezgoda, Jorge Gómez, V. Alberto Laguna-Torres and Charles Rupprecht. Evidence of Rabies Virus Exposure among Humans in the Peruvian Amazon. Am. J. Trop. Med. Hyg. 87:206 (2012).

Related:

How lethal is ebolavirus?

Should we fear avian H5N1 influenza?

Evidence for influenza H5N1 infections in humans

The fatality rate for human infections with avian influenza H5N1 is widely quoted at >50%, based on the number of deaths among the fewer than 600 cases confirmed by the World Health Organization. Wang, Parides, and Palese suggest that this number is an overestimate:

…the stringent criteria for confirmation of a human case of H5N1 by WHO does not account for a majority of infections, but rather, the select few hospitalized cases that are more likely to be severe and result  in poor clinical outcome.

To address this problem, the authors summarized the results of serological surveys in which human sera were examined for the presence of antibodies to influenza H5N1 virus. Because antibodies are part of our immune defenses, they are a good indicator of a previous infection.

The authors searched the scientific literature and identified 20 studies in which human sera were examined for the presence of H5N1 antibodies according to WHO guidelines (a 4-fold or greater increase in neutralizing antibody titer in paired acute and convalescent sera, with the convalescent serum having a titer of ≥1:80, or an antibody titer of ≥1:80 in a single serum collected at day 14 or later after onset of symptoms and a positive result using a different serological assay).

Studies that used the WHO criteria included 7,304 study participants. Rates of seropositivity were from 0 – 5.3%, with one study reporting 11.7% positivity. The meta-analysis yielded a seropositivity rate of 1.2% (95% confidence interval 0.6% – 2.1%). When only poultry workers were considered, the seropositivity rate was 1.4%.

Other studies were separately analyzed that did not utilize WHO guidelines; these included 6,774 participants and yielded a seropositivity rate of 1.9% (95% confidence interval 0.5 – 3.4%).

A total of 12,677 study participants from 20 studies were included in this meta-analysis, of which 1-2% had evidence for prior H5N1 infection. The authors conclude:

…avian H5N1 viruses can cause a rate of mild or subclinical infections in humans that is not currently accounted for and thus, the true fatality rate for H5N1 influenza viruses is likely to be less than the frequently reported rate of more than 50%.

It seems very clear that standardized, large scale studies are needed to determine the real number of human H5N1 infections. This information is critical for assessing the actual threat of H5N1 influenza for humans.