Diagnostic Microbiology and Infectious Disease 69 (2011) 419–427www.elsevier.com/locate/diagmicrobio
Influenza C virus surveillance during the first influenza A (H1N1) 2009pandemic wave in Catalonia, Spain☆,☆☆
Andrés Antóna,⁎, María A. Marcosa, Francisco M. Codoñerb, Patricia de Molinaa,Anna Martínezc, Neus Cardeñosac, Pere Godoyc, Nuria Tornerc, Miguel J. Martíneza,
Susana Ramóna, Griselda Tudóa, Ricard Isantaa, Verónica Gonzaloa,María T. Jiménez de Antaa, Tomàs Pumarolaa
aVirology Section, Microbiology Department, Barcelona Centre for International Health Research (CRESIB, Hospital Clínic - Universitat de Barcelona),08036 Barcelona, Spain
bIrsiCaixa Retrovirology Laboratory-HIVACAT, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, SpaincDepartment of Health, Generalitat de Catalunya, 08005 Barcelona, Spain
Keywords: Influenza C virus; Pandemic wave; Surveillance
1. Introduction
Particular attention is paid to influenza A and B virusisolates during influenza surveillance, especially after thedeclaration of influenza A (H1N1) 2009 pandemic situationby the World Health Organization in June 2009 (currentinformation at http://www.who.int/csr/disease/swineflu/en/index.html). However, infection with influenza C virus(FLUCV) usually coincides with influenza A and influenzaB virus activity.
☆ All authors declare no conflicts of interest.☆☆ This work was partially supported by Fondo de Investigación
Sanitaria (FIS PI08/0118) from the Spanish Ministry of Health, Agènciad'Avaluació de Tecnologia i Recerca Mèdiques (AATRM) (grant 402/02/2008),Red Española de Investigación en Patología Infecciosa (REIPI 06/0008).
Little is known about the epidemiology and the clinicalimpact of FLUCV in the general population in Europe(Gouarin et al., 2008; Manuguerra et al., 1992) and espe-cially in Spain (Calvo et al., 2006; Manuguerra et al.,1994). There are few studies concerning FLUCV infectionin Europe since few laboratories provide specific diagnosesof influenza C infection and because of its apparentlybenign nature. Seroepidemiological studies revealed a widedistribution of FLUCV throughout the world, and theacquisition of antibodies to FLUCV during childhoodoccurs in most of the cases (Dykes et al., 1980; Gouarin etal., 2008; Homma et al., 1982; Manuguerra et al., 1992;Matsuzaki et al., 2006; Nishimura et al., 1987; O'Calla-ghan et al., 1980).
The hemagglutinin-esterase (HE) gene of FLUCV hasbeen classically divided into 6 lineages, represented by C/Taylor/1233/47, C/Aichi/1/81, C/Sao Paulo/378/82, C/
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Kanagawa/1/76, C/Yamagata/26/81, and C/Mississippi/80(Gouarin et al., 2008; Matsuzaki et al., 2003). Phylogeneticstudies of FLUCV strains suggested that strains belongingto different lineages are co-circulating (Matsuzaki et al.,1994, 2003).
People infected with FLUCV may exhibit symptoms witha similar severity to that caused by influenza A and B virusinfections. FLUCV usually causes upper respiratory tractinfections in children and young adults (Gouarin et al., 2008;Greenbaum et al., 1998; Katagiri et al., 1983; Manuguerraet al., 1992), although it can also cause lower respiratoryinfections, such as bronchitis, bronchiolitis, or pneumonia(Calvo et al., 2006; Moriuchi et al., 1991).
In addition to regular virological surveillance thatprovides information about the incidence and the exact roleof FLUCV in acute viral respiratory infections in the generalpopulation, the genetic lineage identification offers moredata for epidemiological purposes.
We present a prospective study of a nonhospitalizedgeneral population in whom the incidence and the geneticlineage identification of FLUCV strains detected during thefirst influenza A (H1N1) 2009 pandemic wave are reported.
2. Materials and methods
2.1. Surveillance system
Influenza Surveillance in Catalonia (PIDIRAC: Plad'informació de les infeccions respiratòries agudes aCatalunya. Departament de Salut, Generalitat de Catalunya.Available at http://www.gencat.cat/salut/depsalut/html/ca/dir3157/plapidirac.pdf), located in Northeastern Spain, isbased on a medical sentinel network that includes 56 physi-cians from 25 primary care centers which covers approxi-mately 1% of the total population. This network provides awide geographical coverage of influenza virus incidence inCatalonia, facilitating timely information exchange oninfluenza activity. Clinical data of the patients are recordedprospectively by sentinel physicians.
2.2. Clinical specimens and virus detection
From 27 April 2009 (week 17/2009) to 9 May 2010 (week18/2010), nasopharyngeal samples (nasal and oropharyngealswabs) were collected from patients with upper respiratorytract illness (URTI) and placed in a tube with viral transportmedium. Within the first 24 h, they were processed in Bio-safety Level 2 Plus (BSL 2+) facilities, being kept at 2–4 °Cin several aliquots until use. Total nucleic acids wereextracted from 200 μL of fresh specimen and eluted in 25 μLof RNase-free elution buffer using NucliSENS easyMAG(bioMérieux, Marcy l'Etoile, France) according to themanufacturer's instructions. Nucleic acids were kept frozenuntil use.
Two independent multiplex nested reverse transcriptionpolymerase chain reactions previously described (Coiras
et al., 2003, 2004) were used to detect human influenzaviruses (types A, B, and C) and other human respiratoryviruses. In those laboratory-confirmed positive samples forinfluenza A virus, a specific 1-step multiplex real-time RT-PCR was used for subtyping (H1/H3/H5/pandemic H1) asdescribed (Anton et al., 2010).
2.3. Nucleotide sequencing
The coding region (CDS) from nucleotides 23 to 1989 ofthe HE gene was sequenced by a PCR-based sequencingmethod from laboratory-confirmed FLUCV-infected respi-ratory specimens. Direct PCR sequencing was done usingoverlapping primer pairs, available upon request, by nestedPCR. Purified PCR products using Exo-SAP-IT (USB,Affymetrix, Inc., Cleveland, OH, USA) were sequenced bythe ABI Prism BigDye Terminator cycle sequencing kit v.3.1 on an ABI 3130XL automatic sequencer (Applied Bio-systems, Foster City, CA, USA). The nucleotide sequenceswere assembled and edited using the SeqScape v. 2.5 soft-ware (Applied Biosystems).
2.4. Phylogenetic analysis
Sequences of the present study and representativesequences of each lineage, previously published (Buona-gurio et al., 1985; Matsuzaki et al., 1994; 2000; 2002; 2003;2004; 2007; Muraki et al., 1996; 2004), were downloadedfrom the GISAID Database and aligned using ClustalX v.2.0.12 (Larkin et al., 2007) with default parameters. Afteralignment of the HE sequences without the initial signalpeptide sequence (MFFSLLLMLGLTEA, Signal PeptideDatabase, http://www.signalpeptide.de), ambiguous regions(i.e., containing gaps and/or poorly aligned) were removedwith Gblocks (v. 0.91b) (Castresana, 2000) using the fol-lowing parameters: at least 10-base pair length of a blockafter gap cleaning, no gap positions allowed in the finalalignments, and rejection of segments with contiguous non-conserved positions bigger than 8 bases. The conversionamong different file formats of multiple sequence alignmentwas done with ALigment Transformation EnviRonment(ALTER) (Glez-Pena et al., 2010). The molecular evolu-tionary model of nucleotide substitution was fitted to themultiple sequence alignment using jModelTest v. 0.1.1(Posada, 2008). The phylogenetic tree was reconstructedusing 2 approaches: i) a maximum likelihood method asimplemented in the PhyML v. 3.0 program (Guindon andGascuel, 2003) and ii) a neighbor-joining distance method asimplemented in Mega v. 4.1 (Tamura et al., 2007) with thebest evolutionary model found previously in jModelTest andwhich is implemented in each of the programs. Reliabilityfor the internal branch was assessed using the nonparametricbootstrap analysis (500 replicates). Graphical representationand editing of the phylogenetic tree were performed withTree Explorer (available in Mega v. 4.1).
In order to detect those amino acid substitutions thatdefine clades and subclades, the amino acid sequences
421A. Antón et al. / Diagnostic Microbiology and Infectious Disease 69 (2011) 419–427
translated from aligned nucleotide sequences, using ClustalXv. 2.0.12, were studied relative to the HE protein sequence ofthe oldest reference strain (C/Taylor/1233/47) using Amino-Track (Mahalanabis et al., 2006).
3. Results
From 27 April 2009 (week 17/2009) to 9 May 2010 (week18/2010), nasopharyngeal specimens were collected from1713 patients with URTI through the Influenza SurveillanceNetwork. In addition to FLUCV detection in samples from12 (0.70%) patients, influenza A virus infection was alsolaboratory confirmed in 466 (27.20%) samples of which 456(26.62%) were subtyped as influenza A (H1N1) 2009 virus,2 (0.12%) as influenza A (H3N2) virus, and 8 (0.47%)remained unsubtyped. Influenza B virus was also detectedin 3 (0.18%) cases. Most laboratory-confirmed FLUCV-infected specimens were collected from August 2009 toDecember 2009, with the exception of 1 case which wascollected in April 2010, as shown in Fig. 1.
As shown in Table 1, which summarizes the demograph-ical, virological, and clinical data of all 12 FLUCV-infectedpatients, 4 (33.33%) patients were younger than 5 years, 2(16.66%) were between 5 and 14 years old, and the re-maining 6 (50%) were older than 14 years.
Medical records of all 12 infected patients were available.Clinical symptoms were fever (83.33%), cough (83.33%),abrupt onset (75%), odynophagia (66.67%), arthromyalgia(41.67%), and headache (33.33%). None of the infectedpatients required hospital admission.
In 10 cases, FLUCV was detected as a unique etiologicalagent. However, in the 2 remaining cases, it was also de-tected with the human enterovirus in 1 case and with pan-demic influenza A (H1N1) 2009 virus in another case.
After multiple alignment of sequences that code to the HEprotein without the initial signal peptide using ClustalX andthe selection of conserved blocks with Gblocks (v. 0.91b),1923 positions were finally selected for phylogeneticanalysis. After collapsing the sequences to haplotypes by
Fig. 1. Weekly distribution of influenza C virus cases in Catalonia during the 200lines show the number of laboratory-confirmed pandemic influenza A (H1N1) 20
ALTER, the molecular evolutionary model of nucleotidesubstitution was fitted to the multiple sequence alignmentusing jModelTest v. 0.1.1 (Posada, 2008). The TVM + I + Gsubstitution model was selected assuming a proportion ofinvariant sites (of 0.4980) and 4 gamma-distributed ratecategories to account for rate heterogeneity across sites. Thegamma-shaped parameter was fixed (alpha = 0.7600). Thephylogenetic tree was reconstructed using the 2 approachesas previously described in the Materials and Methods section.A Shimodaira–Hasegawa test (Shimodaira and Hasegawa,1999), which is implemented in the program PAML v. 4(Yang, 2007), was performed in order to determine as towhich phylogenetic tree most likely explains the evolution ofthe sequences in the analysis. This test pointed to themaximum likelihood tree obtained with PHYML as the mostlikely hypothesis for the evolution of our sequences givenour alignment. We therefore used this topology (Fig. 2) in allour downstream evolutionary analyses.
Phylogenetic analysis revealed that 9 of the recentlycirculating FLUCV viruses fell within clade correspondingto the C/Kanagawa/1/76-related lineage and 3 in clade ofC/Sao Paulo/378/82-related lineage, as shown in Fig. 2.Neither geographical nor chronological relationships werefound among the several cases as shown in Table 1.
Relative to the C/Taylor/1233/47 strain, some amino acidresidue substitutions in the HE coding sequence are associatedwith major genetic clades, while others appear to be associatedwith new genetic groups, as shown in Table 2. Viruses withinthe C/Sao Paulo/378/82-lineage clade have characteristicamino acid substitutions of S76T, E88A, N139D, R142S,Q162K, Q179H, V184T, K207E, I209K, T281S, L292I,L324P, H340Y, Y346C, I388V, T401A, I439T, T517S,T637A, and P638A. Additional amino acid changes in E208Dand V328I were found in sequences of C/Catalonia/1284/2009 and C/Catalonia/1318/2009 strains that are closelyrelated to the phylogenetic tree. Sequence of the C/Catalonia/1430/2009 strain has new substitutions of E337Q, Q372K,and N588D. Viruses within the C/Kanagawa/1/76-lineageclade have characteristic amino acid substitutions of A182K,
9–2010 season. The columns show the influenza C virus-positive cases; the09 positive cases.
FLUAV = Influenza A virus; HEV = human enterovirus.
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Fig. 2. Phylogenetic reconstruction of the FLUCV HE coding sequence(CDS) without the initial signal peptide (from nucleotide 43 to 1968 of theHE CDS). The topology was inferred by the maximum likelihood approachimplemented in the PHYML program using the settings for the bestevolutionary model, TVM + I + G, determined by jModelTest. Values at thenodes are bootstrap supports based on 500 replicates.
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K186G, N204K, K207E, E208N, I209K, F217S, L231M,D253G, T281S, L324P, E337K, H340Y, Y346C, I362V,T401A, I439T, I507T, T517S, N597D, T637A, and P638A.Within this clade, 3 new genetic groups are characterized byadditional changes in 1) S76G and Q372R; 2) K75R; and 3)Q179R, E228D, I388V, and E402K.
The 12 nucleotide sequences determined in this studywere finally submitted to the GenBank database and wereassigned accession numbers HM748623 to HM748634.
4. Discussion
In the present study, the incidence and co-circulation of2 different influenza C lineages in Catalonia (Spain) duringthe surveillance of pandemic influenza A (H1N1) 2009 virusare reported.
The detection of 12 influenza C virus infection cases fromApril 2009 to May 2010 was particularly interesting because,while influenza A (H1N1) 2009 virus remained the pre-dominant virus, the activity of seasonal influenza virusessubtype A (H3N2) and type B during the first pandemicwave in Catalonia was particularly very low.
Although most of the FLUCV infections reported in theliterature were during the winter season, the existence ofsummer infections has also been described by some authors(Gouarin et al., 2008; Greenbaum et al., 1998; Ionita et al.,1992; Katagiri et al., 1983; Matsuzaki et al., 2002; Moriuchiet al., 1991). In the present study, influenza surveillancerevealed that the major circulation (7/12) of FLUCVoccurred from mid–late August 2009 to September 2009.
Seroepidemiological studies of FLUCV infection in othercountries indicate that people acquire antibodies to influenzaC during childhood (Gouarin et al., 2008; Homma et al.,1982; Manuguerra et al., 1992; Matsuzaki et al., 2006;Nishimura et al., 1987; O'Callaghan et al., 1980), althoughFLUCV appears to be one of the many viruses that causeacute upper respiratory tract infections in adults (Hirsilaet al., 2001). A seroepidemiological survey in adults andchildren living in Spain in October 1990 showed a highseroprevalence (between 59.3% and 64.9%) as well as highantibody titers (which ranged from 20 to 320), suggesting anextensive circulation of FLUCV (Manuguerra et al., 1994).Although the incidence of influenza C virus was very low, itis important to note that 6 of 12 patients in this study wereolder than 14 years. It might be explained by the fact thatimmune protection acquired in previous infection duringchildhood may be reduced or lost as a consequence ofantigenic change in the new infecting strains, as occurs withinfluenza A and B viruses.
The multiplex RT-PCR used in this study allowed thedetection of coinfection with other respiratory viruses in 2cases. As reported, coinfection is not a rare event betweenrespiratory viruses and has also been described with FLUCV(Calvo et al., 2006; Matsuzaki et al., 2006). However, agreater number of positive cases are required to establish areal coinfection rate and to understand the role of coinfectionin the clinical prognosis and management.
FLUCV infection usually causes an upper respiratory tractillness with fever, cough, and rhinorrhea, which is compatiblewith the criteria of URTI (Matsuzaki et al., 2006). In thecurrent study, all FLUCV-infected patients had a clinicaldiagnosis of influenza like illness, and there were nosymptoms that could differ between FLUCV infection andinfluenza A or B virus infection. During the time to collec-tion of the respiratory samples, all patients were attended toin primary care units and later on none of them required
Table 2Amino acid changes of viruses that belong to the C/Kanagawa/1/76- and C/Sao Paulo/378/82-related lineages relative to the C/Taylor/1233/47 strain
S E P N R Q Q V V N K E I T L L V V E H Y K Q I T I T N T P —
C/Catalonia/1284/2009
T A — D S K H — T K E D K S I P I I K Y C R — V A T S — A A C/SaoPaulo/378/82
C/Catalonia/1318/2009
T A — D S K H A T — E D K S I P I I K Y C R — V A T S — A A —
C/Yamagata/27/2004
T A — D S K H A T K E — K S I P — I K Y C R — V A T S — A A —
C/Catalonia/1430/2009
T A — D S K H A T K E — K S I P — — Q Y C — K V A T S D A A —
C/Yamagata/1/93 T A A D S K H A T K E — K S I P — I K Y C — — V A T S — A A —C/Miyagi/5/93 T A — D S K H A T K E — K S I P — I K Y C — — V A T S — A A —C/Sao Paulo/378/82 T A — D S K H A T K E — K S I P — — K Y C — — V A T S — A A —
G K S R R N K M Q A K N N K E I K F T Q E L D S R T L V E H —
C/Miyagi/12/2004
— — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y C/Kanagawa/1/76
C/Osaka/2/2004 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Hiroshima/246/2000
— — — — — D — L — K G — K E N K E S — R — M G — — S P I K Y —
C/Niigata/1/2004 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Fukuoka/3/2004 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Saitama/3/2000 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Hiroshima/251/2000
— — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Hiroshima/250/2000
— — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Yamagata/3/2004 — — — — — D — L — K G — K E N K E S I R — M G — — S P I K Y —C/Yamagata/20/2004 — — — — H D R L — K G D K E N K E S I R — M G — — S P I K Y —C/Catalonia/1945/2009
— — G — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Catalonia/1824/2009
— — G — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Catalonia/1373/2009
— R — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Catalonia/1372/2009
— R — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Catalonia/1266/2009
— R — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Catalonia/1754/2009
— R — — — D — L — K G — K E N K E S — R — M G — — S P I K Y —
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C/Catalonia/2072/2009
— R — K — D — L — K G — K E N K E S — R — M G — — S P I K Y —
C/Miyagi/9/96 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Catalonia/1457/
2009— — — — — D — L R K G D K E N K E S — R D M G — — S P I K Y —
C/Catalonia/2588/2010
— — — — — D — L R K G D K E N K E S — R D M G — — S P I K Y —
C/Miyagi/2/2000 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Hiroshima/4/2004 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Fukushima/1/2004 — — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —C/Kanagawa/2/
2004— — — — — D — L — K G D K E N K E S — R — M G — — S P I K Y —
C/Aomori/74 — — — — — — — — — K G D K E N K — S — — — M G — G S P — K Y —C/Miyagi/77 — — — — — — — — — K G — K E N K E S — — — M G — — S P — K Y —C/Kanagawa/1/76 E — — — — — — — K K G D K E N K E S — — — M G A — S P I K Y —
Y Q I Q G I T E S I L R K R I T V N A T P — — — — — — — — — —
C/Miyagi/12/2004 C K V — — — A — G T — — R — T S — D V A A C/Kanagawa/1/76C/Osaka/2/2004 C K V — — — A — G T — — R — T S — D — A A — — — — — — — — — —C/Hiroshima/246/
2000C K V — — — A — G T — — R — T S — D — A A — — — — — — — — — —
C/Niigata/1/2004 C — V — — — A — G T — — — — T S — D — A A — — — — — — — — — —C/Fukuoka/3/2004 C — V — — — A — G T — — — — T S — D — A A — — — — — — — — — —C/Saitama/3/2000 C — V — — — A — — T — — — — T S — D — A A — — — — — — — — — —C/Hiroshima/251/
2000C — V — — — A — — T — — — — T S I D — A A — — — — — — — — — —
C/Hiroshima/250/2000
C — V — — — A — — T — — — — T S I D — A A — — — — — — — — — —
C/Yamagata/3/2004
C — V K — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Yamagata/20/2004
C — V — — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Catalonia/1945/2009
C — V R — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Catalonia/1824/2009
C — V R — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Catalonia/1373/2009
C — V — — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Catalonia/1372/2009
C — V — — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Catalonia/1266/2009
C — V — — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Catalonia/1754/2009
C — V — — — A — — T — — — — T S — D — A A — — — — — — — — — —
C/Catalonia/2072/2009
C — V — D — A — — T — — — — T S — D — A A — — — — — — — — — —
(continued on next page)
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Table
2(con
tinued)
Strain/po
sitio
n76
8813
413
914
216
217
918
018
420
420
720
820
928
129
232
432
833
133
734
034
635
937
238
840
143
951
758
863
763
8
C/M
iyagi/9
/96
C—
V—
——
A—
—T
——
——
TS
—D
—A
A—
——
——
——
——
—C/Catalonia/1457/
2009
C—
V—
—V
AK
—T
——
——
TS
—D
—A
A—
——
——
——
——
—
C/Catalonia/2588/
2010
C—
V—
—V
AK
—T
——
——
TS
—D
—A
A—
——
——
——
——
—
C/M
iyagi/2
/200
0C
—V
——
—A
——
T—
——
—T
S—
D—
AA
——
——
——
——
——
C/Hiroshima/4/
2004
C—
V—
——
A—
—T
——
——
TS
—D
—A
A—
——
——
——
——
—
C/Fuk
ushima/1/
2004
C—
V—
——
A—
GT
——
——
TS
—D
—A
A—
——
——
——
——
—
C/Kanagaw
a/2/
2004
C—
V—
——
A—
GT
——
——
TS
—D
—A
A—
——
——
——
——
—
C/Aom
ori/7
4C
—V
——
—A
——
TF
K—
—T
S—
D—
AA
——
——
——
——
——
C/M
iyagi/7
7C
—V
——
—A
——
TF
K—
—T
S—
D—
AA
——
——
——
——
——
C/Kanagaw
a/1/76
C—
V—
——
A—
—T
—K
—K
TS
—D
—A
A—
——
——
——
——
—
Table2(contin
ued)
Strain/po
sitio
n34
635
836
237
238
038
840
140
243
443
945
847
547
650
250
751
757
759
763
463
763
8
426 A. Antón et al. / Diagnostic Microbiology and Infectious Disease 69 (2011) 419–427
admission to hospital due to clinical complications or anincrease of the severity of illness. Statistical analysis was notconducted because of the small sample size.
Phylogenetic analysis of the HE gene revealed simulta-neous co-circulation of C/Kanagawa/1/76- and C/Sao Paulo/378/82-related lineages from April 2009 to May 2010. Sincewe do not have data of previous surveillance seasons, wecannot establish a dominant genetic lineage. The circulatingstrains in Catalonia were not only quite distinct from thepreviously described sequences within the 2 lineages, butalso there was quite a diversity between the individual iso-lates identified here. Analysis of the amino acid sequences ofthe HE gene showed additional substitutions in the circu-lating strains of FLUCV in Catalonia which were definingnew genetic groups, especially in the C/Kanagawa/1/76-related lineage. Although FLUCV evolves more slowly thaninfluenza A virus and it is well known that influenza Cviruses have multiple genetic variants belonging to differentevolutionary lineages which coexist in nature (Muraki andHongo, 2010), a continuous virological surveillance forinfluenza C viruses might contribute to a best knowledgeof the circulating FLUCV strains.
The present study is the first report of FLUCV infectionin Catalonia, Spain. It reveals that 2 genetic lineages wereco-circulating, even in the summer–autumn period whenseasonal influenza activity is usually low. During the firstpandemic wave, influenza A (H1N1) 2009 virus was ob-viously the predominant virus, but the number of detec-tions of FLUCV was particularly interesting in contrast tothe low activity of the seasonal influenza A (H3N2) andinfluenza B viruses. Although FLUCV usually causes amild upper respiratory tract illness in the general popula-tion, regular virological surveillance would provide valu-able information about the incidence and the role ofFLUCV in acute viral respiratory infections. Furthermore,genetic lineage identification would offer additional data forepidemiological purposes.
Acknowledgments
The authors would like to thank the Working Group ofInfluenza Surveillance Network in Catalonia.
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