Email updates

Keep up to date with the latest news and content from Diagnostic Pathology and BioMed Central.

Open Access Open Badges Short report

Frequency of D222G haemagglutinin mutant of pandemic (H1N1) pdm09 influenza virus in Tunisia between 2009 and 2011

Awatef El Moussi1, Mohamed Ali Ben Hadj Kacem1, Francisco Pozo2, Juan Ledesma2*, Maria Teresa Cuevas2, Inmaculada Casas2 and Amine Slim1

Author Affiliations

1 National Influenza Centre-Tunis, Unit Virology, Microbiology Laboratory, Charles Nicolle’s Hospital, Tunis, Tunisia

2 National Influenza Centre-Madrid, Influenza and Respiratory Viruses Laboratory, Instituto de Salud Carlos III, Madrid, Spain

For all author emails, please log on.

Diagnostic Pathology 2013, 8:124  doi:10.1186/1746-1596-8-124

Published: 31 July 2013



The novel pandemic A (H1N1) pdm09 virus was first identified in Mexico in April 2009 and since then it spread worldwide over a short period of time. Although the virus infection is generally associated with mild disease and a relatively low mortality, it is projected that mutations in specific regions of the viral genome, especially within the receptor binding domain of the haemagglutinin (HA) protein could result in more virulent virus stains, leading to a more severe pathogenicity.


To monitor the genetic polymorphisms at position 222 of Haemagglutinin of influenza A(H1N1)pdm09 viruses from both outpatients with mild influenza and individuals with severe disease requiring hospitalization, during 2009–2010 and 2010–2011 seasons, a sequence-based genotypic assessment of viral populations to understand the prevalence of D222G mutation.


The D222G was identified in clinical specimens from 3 out of 42 cases analyzed in Tunisia with severe outcome (7%). Interestingly, in one fatal case out of four viruses taken from fatal cases studied (25%). Also this mutation was found in one mild case out of 8 mild cases studied (0.1%). D222E substitution was found in virus taken from one patient with severe clinical syndrome (2%) out of 42 severe cases analyzed and E374K substitution was found in two severe cases (4%) out of 42 severe cases studied.


A specific mutation in the viral haemagglutinin (D222G) was found in fatal, severe and mild case. Further virological, clinical and epidemiological investigations are needed to ascertain the role of this and other mutations that may alter the virulence and transmissibility of the pandemic influenza A (H1N1)pdm09.

Virtual Slides

The virtual slide(s) for this article can be found here: webcite

D222G substitution; Haemagglutinin; Influenza A(H1N1)pdm09 virus; Pandemic; Severe respiratory infection