PE R S PE C T IV E
Focus on Rese arch
H5N1 Influenza — Continuing Evolution and Spread
Robert G. Webster, Ph.D., and Elena A. Govorkova, M.D., Ph.D.
T here is no question that there
will be another influenza pan-
demic someday. We simply don’t
know when it will occur or wheth-
er it will be caused by the H5N1
avian influenza virus. But given
the number of cases of H5N1 in-
fluenza that have occurred in
humans to date (251 as of late
September 2006) and the rate of
death of more than 50%, it would
be prudent to develop robust plans
for dealing with such a pandemic.
The epicenters of both the
Asian influenza pandemic of 1957
and the Hong Kong influenza pan-
demic of 1968 were in Southeast
Asia, and it is in this region that
multiple clades of H5N1 influ-
enza virus have already emerged.
The Asian H5N1 virus was first
detected in Guangdong Province,
China, in 1996, when it killed
some geese, but it received little
attention until it spread through
live-poultry markets in Hong Kong
to humans in May 1997, killing
6 of 18 infected persons (see map
and time line). The culling of all
poultry in Hong Kong ended the
first wave of H5N1, but the vi-
rus continued to circulate among
apparently healthy ducks in the
coastal provinces of China.
From 1997 to May 2005, H5N1
viruses were largely confined to
Southeast Asia, but after they had
infected wild birds in Qinghai
Lake, China, they rapidly spread
westward. The deaths of swans
and geese marked H5N1’s spread
into Europe, India, and Africa.
Infections with highly patho-
genic H5N1 viruses were con-
firmed in poultry in Turkey in
2174 n engl j med 355;21
H5N1 Influenza — Continuing Evolution and Spread
Related articles, p. 2179 and 2186
mid-October 2005, and the first
confirmed human cases in Turkey
occurred in early January 2006.
Thus, H5N1 influenza viruses
continue to emerge from the epi-
center.
The H5N1 viruses can be di-
vided into clade 1 and clade 2; the
latter can be further subdivided
into three subclades. The bad news
is that these clades and subclades
probably differ sufficiently in their
antigenic structure to warrant the
preparation of different vaccines.
Studies in ferrets suggest that
vaccine against one clade will not
protect against infection with
another clade, though it will pro-
tect against influenza-associated
death.1 Thus, the available infor-
mation supports the notion that
a vaccine against H5N1 is worth
stockpiling as a “prepandemic”
vaccine, since very few persons
have been immunologically ex-
posed to H5 antigens and priming
with one clade may be beneficial.
Another key question is wheth-
er these clades and subclades vary
in sensitivity to available anti-
influenza drugs. The majority of
H5N1 clade 1 viruses (e.g., A/Viet-
nam/1203/2004) are resistant to
the adamantanes (amantadine and
rimantadine), but the majority of
clade 2 viruses (e.g., A/Indonesia/
5/2005) are sensitive. All H5N1
viruses that have been tested are
sensitive to the neuraminidase in-
hibitors; these drugs may be ef-
fective when used prophylactically,
but the window for effective treat-
ment will probably be limited to
1 to 2 days after initial infection.
Kandun et al. make clear in their
www.nejm.org november 23, 2006
report in this issue of the Journal
(pages 2186–2194) on three clus-
ters of patients with H5N1 infec-
tion in Indonesia that the difficulty
with the use of a neuraminidase
inhibitor (oseltamivir) in those
cases was that treatment began
5 to 7 days after initial infection.
Such delayed administration of the
drug limits its value in decreasing
the viral load and might lead to
the selection of resistant strains.
The use of rapid diagnostics for
H5N1 virus infection can permit
specific antiviral treatments to be
initiated early. Oner et al. report
in this issue of the Journal (pages
2179–2185) that in a human out-
break of H5N1 in Turkey, it was
difficult to detect H5N1 virus in-
fection with standard techniques;
the authors found that a real-time
polymerase-chain-reaction assay
performed on nasopharyngeal
The Spread of H5N1 Influenza Virus
and Time Line Showing Its Emergence.
The shaded area across southern China
is the hypothetical epicenter for the
emergence of H5N1 clades and sub-
clades. The H5N1 viruses are being
perpetuated in the domestic birds of
the region, despite the use of univer-
sal vaccination of all domestic poultry.
The red dot in the time line denotes
the occurrence of the first human
case, followed by the number of con-
firmed human cases in that country.
The green and blue solid bars repre-
sent documented H5N1 infection in
domestic poultry and wild birds, and
dashed bars indicate that H5N1 in the
avian population is suspected. These
limited surveillance data are adapted
from the World Health Organization
and the U.N. Food and Agriculture
Organization (www.fao.org). HA
denotes hemagglutinin.
PE R S PE C TI V E H5N1 Influenza — Continuing Evolution and Spread

Spread of H5N1 Influenza Virus

Russia

Cla
d
e2
Turkey

−S
Qinghai China
South Korea

ub
Japan
Lake

cla
de
2
5−2006)
200

(20
3(

05
−2

4)
00 de

00
6)

la

−2
bc

03
Su

(20
2−
Egypt

e1
e
ad
ad
Cl

)
Cl
006
Lao

lade 1 (2004−2
PDR

Thailand

ubc
Vietnam

2−S
Djibouti

de
Cambodia

Cla
Indonesia

Time Line of Emergence of H5N1 Influenza Virus

AFRICA
14
Egypt

Djibouti 1

EUROPE

Russia

Pakistan
First human case
India Domestic poultry
Wild birds 8
Azerbaijan
2
Iraq
Daughter dies in Fujian, Bar-headed geese at
father dies in Hong Kong, Qinghai Lake die-off 12
Turkey
son recovers
Mongolia
68
Indonesia Exotic waterfowl in
Hong Kong die-off 93
Vietnam
25
Thailand

Lao PDR All poultry in Hong

Kong are culled 6
Cambodia

Japan

South Korea
Hong Kong 18 3
(China)
21
China

Year 1996 1997 1998 2003 2004 2005 2006

Clade 1
Clade 2

HA Clade
Subclade 1
Subclade 2
Subclade 3

n engl j med 355;21 www.nejm.org november 23, 2006 2175

PE R S PE C T IV E
specimens had the best diagnos-
tic value.
The continuing evolution of
H5N1 viruses and the clusters of
human infections in Indonesia and
Turkey raise important questions.
First, can the source of H5N1 be
eliminated? And second, is the
increasing number of clusters of
human infection an indicator of
evolution toward consistent hu-
man-to-human transmission?
Controlling H5N1 influenza
by eradicating it at the source in
domestic poultry has worked for
some wealthy countries: in 2003,
Japan and South Korea eradicated
H5N1 through a strategy of quar-
antine and culling of poultry and
implementation of improved bio-
security measures for poultry fa-
cilities. In Thailand, however, the
same strategy resulted in only a
temporary respite; after nearly a
year with no H5N1 activity, new
cases in humans in July 2006 her-
alded the resurgence of H5N1 in
domestic poultry.
An alternative strategy adopted
by China, Indonesia, and Vietnam
has been to vaccinate uninfected
poultry in conjunction with the
quarantine and culling of infected
birds. This approach has failed,
however, and its critics explain
that poultry vaccines are largely
of poor quality, do not provide
sterilizing immunity, and promote
antigenic drift. Yet vaccines against
H5N1 influenza virus have been
used successfully since 2004 on
all poultry sold in Hong Kong,
where no H5N1 virus has been
isolated from fowl in live-bird
markets despite extensive pro-
spective surveillance.
Perhaps the most important
experiment in controlling H5N1
is one that is ongoing in Vietnam.
Since the country adopted a strat-
egy of vaccinating all poultry with
2176 n engl j med 355;21
H5N1 Influenza — Continuing Evolution and Spread
inactivated, oil-emulsion H5N1
vaccine, there have been no ad-
ditional cases in humans and no
reported H5N1 infections in chick-
ens. But in September 2006, H5N1
was reported to have reemerged
in ducks and geese in Vietnam.
The virus is
always changing,
and mutations
that make it
more compatible
with human
transmission
may occur at
any time.
Thus, H5N1 influenza vaccine
seems to protect chickens and,
indirectly, humans, but probably
not waterfowl.
Given that the vaccine pre-
dominantly used in Vietnam is
prepared in China, where the
policy is to vaccinate all poultry,
some have questioned why H5N1
is not under control in China.
The problem may be the lack of
protection in waterfowl. Ducks
may be the stealth carriers (the
Trojan horses of H5N1 influen-
za), for wild mallard ducks do
not always show signs of disease
when infected with any of a
range of highly pathogenic H5N1
viruses.2 Our knowledge about
the efficacy of H5N1 influenza
vaccines in domestic waterfowl is
limited, and highly pathogenic
H5N1 viruses continue to be iso-
lated from waterfowl in the epi-
center of the epidemic. If the res-
ervoir of highly pathogenic H5N1
www.nejm.org november 23, 2006
virus is domestic waterfowl, the
virus should theoretically be erad-
icable, but eliminating it would
require improved vaccines for wa-
terfowl and draconian prospective
surveillance and culling.
Meanwhile, the number of in-
fections in humans continues to
increase. By mid-August, 97 hu-
mans had been infected in 2006
— the same number as in all of
2005. Perhaps the most surpris-
ing thing about highly pathogen-
ic H5N1 is that although more
than 230 million domestic birds
have died or been killed, only 251
humans have become ill from
H5N1 infection, and there has
been little or no evidence of sub-
clinical infection in humans. The
current H5N1 virus is apparently
not well “fitted” to replication in
humans, although the genetic
makeup of a small proportion of
humans supports attachment and
replication of the virus, if not its
transmission. The specific recep-
tor for the current avian influen-
za virus (α2-3 sialic acid) is found
deep in the respiratory tract of
humans,3 but it seems likely that
only a minority of people have
receptors for avian influenza vi-
ruses in their upper respiratory
tracts. Moreover, receptor speci-
ficity is only one of the require-
ments for human infection; the
virus must also find compatible
enzyme systems in the infected
human cells if the viral polymer-
ase complex is to function. Cur-
rently, these conditions are appar-
ently met in only a few persons.
But the virus is always changing,
and mutations that make it more
compatible with human transmis-
sion may occur at any time.
The seasonality of H5N1 in-
fluenza seems similar to that of
human influenza: the virus has
apparently been more transmis-
PE R S PE C TI V E
sible among chickens, and con-
sequently to humans, during the
cooler months. The cases in hu-
mans in Turkey, Iraq, and Egypt
occurred during the cooler months
and coincided with explosive out-
breaks of the disease in wild and
domestic poultry. In the tropical
areas of Asia, there have been two
resurgences of H5N1 during the
warmer months of the year — a
pattern that resembles that fol-
lowed by human influenza in the
tropics, with its multiple peaks of
activity. With winter approaching
in the northern hemisphere, H5N1
may spread further. Will it cross
from Eurasia to the Americas?
Will wild migratory birds carry
it from their breeding sites in
n engl j med 355;21
H5N1 Influenza — Continuing Evolution and Spread
northern Europe and Siberia to
commercial poultry in Europe,
Africa, and America? If it is en-
demic in wild migratory birds
that are not rapidly killed by it,
then spread to domestic backyard
poultry is inevitable. The intermit-
tent spread to humans will con-
tinue, and the virus will continue
to evolve.
Clearly, we must prepare for
the possibility of an influenza pan-
demic. If H5N1 influenza achieves
pandemic status in humans —
and we have no way to know
whether it will — the results could
be catastrophic.
Drs. Webster and Govorkova report re-
ceiving research funding from Hoffmann–
La Roche and BioCryst Pharmaceuticals.
Dr. Webster reports receiving consulting fees
www.nejm.org november 23, 2006
from GlaxoSmithKline; and Dr. Govorkova,
consulting fees from BioCryst Pharmaceu-
ticals. No other potential conflict of inter-
est relevant to this article was reported.
Dr. Webster is a professor and Dr. Gov-
orkova a senior scientist in the Depart-
ment of Infectious Diseases, Division of
Virology, St. Jude Children’s Research Hos-
pital, Memphis, TN.
1. Govorkova EA, Webby RJ, Humberd J,
Seiler JP, Webster RG. Immunization with
reverse-genetics-produced H5N1 influenza
vaccine protects ferrets against homologous
and heterologous challenge. J Infect Dis
2006;194:159-67.
2. Hulse-Post DJ, Sturm-Ramirez KM, Hum-
berd J, et al. Role of domestic ducks in the
propagation and biological evolution of
highly pathogenic H5N1 influenza viruses
in Asia. Proc Natl Acad Sci U S A 2005;102:
10682-7.
3. Shinya K, Ebina M, Yamada S, Ono M, Ka-
sai N, Kawaoka Y. Avian flu: influenza virus
receptors in the human airway. Nature 2006;
440:435-6.
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