In Vitro Assessment of Attachment Pattern and Replication Efficiency of H5N1 Influenza A Viruses with Altered Receptor Specificity

The continuous circulation of the highly pathogenic avian influenza (HPAI) H5N1 virus has been a cause of great concern. The possibility of this virus acquiring specificity for the human influenza A virus receptor, α2,6-linked sialic acids (SA), and being able to transmit efficiently among humans is a constant threat to human health. Different studies have described amino acid substitutions in hemagglutinin (HA) of clinical HPAI H5N1 isolates or that were introduced experimentally that resulted in an increased, but not exclusive, binding of these virus strains to α2,6-linked SA. We introduced all previously described amino acid substitutions and combinations thereof into a single genetic background, influenza virus A/Indonesia/5/05 HA, and tested the receptor specificity of these 27 mutant viruses. The attachment pattern to ferret and human tissues of the upper and lower respiratory tract of viruses with α2,6-linked SA receptor preference was then determined and compared to the attachment pattern of a human influenza A virus (H3N2). At least three mutant viruses showed an attachment pattern to the human respiratory tract similar to that of the human H3N2 virus. Next, the replication efficiencies of these mutant viruses and the effects of three different neuraminidases on virus replication were determined. These data show that influenza virus A/Indonesia/5/05 potentially requires only a single amino acid substitution to acquire human receptor specificity, while at the same time remaining replication competent, thus suggesting that the pandemic threat posed by HPAI H5N1 is far from diminished.Influenza A virus is a negative-strand RNA virus with a segmented genome within the family of Orthomyxoviridae. Influenza A viruses are divided into subtypes based on the surface glycoproteins hemagglutinin (HA) and neuraminidase (NA). Currently, 16 subtypes of HA and 9 subtypes of NA have been identified in the natural reservoir of all influenza A viruses, wild aquatic birds (24). Occasionally, viruses from this reservoir cross the species barrier into mammals, including humans. When animal influenza viruses are introduced in humans, the spread of the virus is generally limited but may on occasion result in sustained human-to-human transmission. Three influenza A virus subtypes originating from the wild bird reservoir—H1, H2, and H3—have formed stable lineages in humans, starting off with a pandemic and subsequently causing yearly influenza epidemics. In the 20th century, three such pandemics have occurred, in 1918 (H1N1), 1957 (H2N2), and 1968 (H3N2). In 2009, the swine-origin H1N1 virus caused the first influenza pandemic of the 21st century (23).Efficient human-to-human transmission is a prerequisite for any influenza A virus to become pandemic. Currently, the determinants of efficient human-to-human transmission are not completely understood. However, it is believed that a switch of receptor specificity from α2,3-linked sialic acids (SA), used by avian influenza A viruses, to α2,6-linked SA, used by human influenza viruses, is essential (6, 17, 31). It has been shown that the difference in receptor use between avian and human influenza A viruses combined with the distribution of the avian and human virus receptors in the human respiratory tract results in a different localization of virus attachment (26, 33-35). Human viruses attach more abundantly to the upper respiratory tract and trachea, whereas avian viruses predominantly attach to the lower respiratory tract (5, 33-35). Theoretically, the increased presence of virus in the upper respiratory tract, due to the specificity of human influenza A viruses for α2,6-linked SA, could facilitate efficient transmission.Since 1997, highly pathogenic avian influenza (HPAI) H5N1 virus has been circulating in Southeast Asia and has spread westward to Europe, the Middle East, and Africa, resulting in outbreaks of HPAI H5N1 virus in poultry and wild birds and sporadic human cases of infection in 15 different countries (38). The widespread, continuous circulation of the HPAI H5N1 strain has spiked fears that it may acquire specificity for α2,6-linked SA, potentially resulting in a pandemic. Given the currently high case fatality rate of HPAI H5N1 virus infection in humans of ca. 60%, the effect of such a pandemic on the human population could be devastating. In recent years, several amino acid substitutions in HA of HPAI H5N1 viruses have been described, either in virus isolates from patients or introduced experimentally, that increased the binding of the HPAI H5N1 HA to α2,6-linked SA (1, 2, 10, 14, 16, 29, 39, 40). However, none of the described substitutions conferred a full switch of receptor specificity from α2,3-linked SA to α2,6-linked SA and the substitutions were described in virus strains of different geographical origins. Furthermore, it is unknown whether these substitutions led to increased attachment of the virus to cells of the upper respiratory tract, the primary site of replication of human influenza A viruses.Here, we have introduced all of the 21 previously described amino acid substitutions or combinations thereof that changed the receptor specificity of HPAI H5N1 virus strains and six additional combinations not previously described, into HA of influenza virus A/Indonesia/5/05 (IND05). Indonesia is the country that has the highest cumulative number of human cases of HPAI H5N1 virus infection (38). The receptor specificity of 27 mutant H5N1 viruses was determined and the attachment pattern of a subset of these viruses to tissues of the respiratory tract of ferret and human was determined and compared to the attachment pattern of human influenza A virus (H3N2). Subsequently, the role of NA in efficient replication of these mutant viruses was investigated. The data presented here show that receptor specificity of HA of the IND05 virus can be changed by introducing a single amino acid substitution in the receptor-binding domain, resulting in replication competent viruses that attach abundantly to the human upper respiratory tract.