On 6 June 2017, the World Health Organization (WHO) published updates to its ‘Essential Medicines List’ (EML). Read more here.

Extended deadline (from 1 July to 31 July) 2017 for call to submit papers on effectiveness and cost-effectiveness of screening and prevention of infectious diseases among newly arrived migrants in Europe. Read more here.

Eurosurveillance is on the updated list of the Directory of Open Access Journals and in the SHERPA/RoMEO database. Read more here.

Follow Eurosurveillance on Twitter: @Eurosurveillanc

In this issue

Home Eurosurveillance Edition  2017: Volume 22/ Issue 18 Article 1
Back to Table of Contents
Download (pdf)

Eurosurveillance, Volume 22, Issue 18, 04 May 2017
Rapid communication
Gubareva, Fallows, Mishin, Hodges, Brooks, Barnes, Fry, Kramp, Shively, Wentworth, Weidemaier, and Jacobson: Monitoring influenza virus susceptibility to oseltamivir using a new rapid assay, iART

+ Author affiliations

Citation style for this article: Gubareva LV, Fallows E, Mishin VP, Hodges E, Brooks A, Barnes J, Fry AM, Kramp W, Shively R, Wentworth DE, Weidemaier K, Jacobson R. Monitoring influenza virus susceptibility to oseltamivir using a new rapid assay, iART. Euro Surveill. 2017;22(18):pii=30529. DOI:

Received:11 April 2017; Accepted:04 May 2017

Early detection of drug-resistant influenza viruses is needed for timely modification of policies and recommendations on the use of antivirals [1]. In many countries, neuraminidase (NA) inhibitor(s) are the medications of choice for treatment and prophylaxis of influenza infections, with oseltamivir being most commonly prescribed. The rapid, global spread of oseltamivir-resistant A(H1N1) viruses that emerged in Norway in 2008, necessitated close monitoring of oseltamivir resistance among circulating influenza viruses [2]. The emergence and subsequent seasonal circulation of the 2009 A(H1N1)pdm09 pandemic virus have further reinforced the need for enhanced surveillance. Moreover, there have been reports of locally transmitted oseltamivir-resistant A(H1N1)pdm09 viruses harbouring the NA amino acid (AA) substitution H275Y [3-5], the marker of clinically relevant resistance to oseltamivir [6,7]. Several genotypic methods (e.g. pyrosequencing) have been implemented by surveillance laboratories to screen clinical specimens for the presence of H275Y [8].

Assays to detect oseltamivir-resistant influenza viruses

Neuraminidase inhibition

Unlike sequence-based assays, the NA inhibition (NAI) assay enables the detection of potentially drug-resistant viruses regardless of underlying genetic change(s). It is the gold standard method for assessing susceptibility to NA inhibitors [9,10]. Interpretation of the NAI assay is based on the determined IC50, a drug concentration needed to inhibit 50% of the NA enzyme activity. Depending on the fold increase of IC50 compared with a control, results are reported as normal (NI), reduced (RI) or highly reduced (HRI) inhibition. In the absence of established laboratory correlates of clinically-relevant oseltamivir resistance, all viruses displaying RI/HRI are considered to be potentially drug resistant and as such are monitored [9,10]. Although useful, this method is labour intensive, complex, and requires propagation of the viruses in cell culture. Additionally, the viral NA sequence from both the isolate and matching clinical specimen should be compared to rule out culturing artefacts [9-11]. Due to the complexity of the assay and data interpretation, testing is mainly performed by specialised surveillance laboratories [10,12,13].

New rapid prototype assay

In this study, we investigated whether the influenza Antiviral Resistance Test (iART), a rapid prototype assay developed by Becton Dickinson R and D for research use only, could be used to improve oseltamivir resistance surveillance by providing a simpler and faster testing method. iART utilises an advanced enzyme substrate that enables measurement of NA activity in virus isolates and in clinical specimens. Unlike the substrate used in the bioluminescence-based assay [14], the substrate used in iART is specific to influenza NA, making it more suitable for testing clinical specimens that may contain other pathogens. In this assay, the sample is divided between two wells of a disposable (Figure), one well containing substrate and the other well containing substrate and oseltamivir carboxylate. A simple device is used to measure the chemiluminescent signal generated from each well of the disposable. The built-in software calculates the ratio of signal intensity between the wells (R-factor), which appears on the device’s display along with the final result: ‘resistant’ or ‘nonresistant’. The threshold between nonresistant and resistant is different for type A and type B viruses, with R-factors of 0.7 and 2.2, respectively. If the NA activity is too low or absent, the message ‘insufficient signal’ appears on the display.


(A) Workflow of iART testing; (B) Prototype device and kit


iART: influenza Antiviral Resistance Test; VTM: viral transport medium.

Respiratory clinical specimens were stored in VTM before testing. The room temperature was monitored throughout the study and was consistently between 21 and 22˚C.

Clinical specimens (n=149) were either applied to the gravity-fed column as is, or were diluted fivefold using viral transport medium (VTM). Virus isolates (n=76) were diluted 100- or 1,000-fold using VTM to meet the assay requirement (40,000 < signal < 6,000,000 luminescent units).

Testing viral isolates using the influenza Antiviral Resistance Test

International reference panel for neuraminidase inhibition assay

In the first experiment, the international reference panel for NAI assay was tested using iART and the United States Centers for Disease Control and Prevention (US CDC) standardised fluorescence-based NAI assay [13] (Table 1). Viruses identified as resistant by iART, displayed RI or HRI by NAI assay; viruses with NI were identified as nonresistant, indicating good agreement between the two assays (Table 1).

Table 1

Results of testing viruses from the international reference panel, for resistance to oseltamivir, using the neuraminidase inhibition (NAI) and influenza Antiviral Resistance Test (iART) assaysa (n=8)

Virus Subtype or Lineage NA amino acid substitutionb NAI assayc iART
Straight numbering N2 numbering IC50, nM (fold)d Interpretatione R-factorf Resultg
A/Mississippi/03/2001 H1N1 None None 0.39 ± 0.05 (1) NI 0.13 ± 0.04 Nonresistant
A/Mississippi/03/2001 H1N1 H275Y H274Y 337.0 ± 28.93 (876) HRI 6.06 ± 0.16 Resistant
A/Perth/265/2009 H1N1pdm09 None None 0.25 ± 0.03 (1) NI 0.12 ± 0.01 Nonresistant
A/Perth/261/2009 H1N1pdm09 H275Y H274Y 171.81 ± 20.66 (1,010) HRI 4.83 ± 0.35 Resistant
A/Fukui/20/2004 H3N2 None None 0.12 ± 0.02 (1) NI 0.16 ± 0.05 Nonresistant
A/Fukui/45/2004 H3N2 E119V E119V 49.53 ± 3.89 (450) HRI 1.01 ± 0.04 Resistant
B/Perth/211/2001 Yamagata None None 15.38 ± 0.98 (1) NI 1.63 ± 0.14 Nonresistant
B/Perth/211/2001 Yamagata D197E D198E 98.08 ± 20.21 (6) RI 3.13 ± 0.10 Resistant

IC50: inhibitory concentration 50%; NA: neuraminidase; R-factor: ratio of chemiluminescent signal intensity generated by viral NA activity on the substrate with and without inhibitor (i.e. oseltamivir carboxylate).

a International Society for Influenza and other Respiratory Virus Diseases Antiviral Group (ISIRV AVG) NAI susceptibility reference panel, a panel of sensitive, resistant and potentially resistant reference viruses to be used as controls for the harmonisation of NAI assays (

b NA amino acid substitution position is shown using both straight numbering (type/subtype specific) and N2 subtype numbering.

c Tested using the United States Centers for Disease Control and Prevention (CDC) standardised fluorescence-based NAI Assay [13].

d IC50, drug concentration required to inhibit 50% of NA activity; mean and standard deviation of at least three independent experiments; Fold, a fold increase in IC50 value compared with the control (IC50 value for the virus lacking the amino acid substitution).

e Criteria for reporting NAI assay results based on IC50 fold increase compared with the reference IC50 value (control virus): for influenza A, normal (< 10-fold), reduced (10–100-fold) and highly reduced (> 100-fold) inhibition, and for influenza B the same criteria, but using < 5-fold, 5–50-fold and > 50-fold increases [9]; NI, normal inhibition; RI, reduced inhibition; HRI, highly reduced inhibition.

f Mean and standard deviation of R-factors; results of at least three independent experiments.

g Output result as shown on the device’s display; result is based on the pre-set cutoffs for influenza A (≥ 0.7) and B (≥ 2.2) viruses.

A(H1N1)pdm09 virus isolates carrying H275Y mutations

Monitoring the spread of A(H1N1)pdm09 viruses exhibiting HRI by oseltamivir and carrying H275Y is a priority for surveillance. To evaluate the ability of iART to detect oseltamivir-resistance conferred by H275Y, 13 virus isolates with this mutation, which had been collected between 2009 and 2016 were tested. All these H275Y viruses exhibited HRI by NAI assay and were also identified as resistant by iART with R-factor of 5.3 ± 0.76 (Table 2).

Table 2

Results from neuraminidase inhibition (NAI) and iART assays for virus isolates carrying NA amino acid mutations conferring various degrees of oseltamivir resistance (n = 42) or no such mutations (controls; n= 4)

Virus NA mutations NAI assay iART
Straight numbering N2 numbering IC50, nM
Mean ± SDa
Fold Interpretationb R-factor, Mean ± SD Resultc
A/Washington/29/2009 H275Y H274Y 208.76 ± 27.05 1,228 HRI 4.1 ± 0.12 Resistant
A/North Carolina/39/2009 H275Y H274Y 199.43 ± 4.38 1,173 HRI 5.17 ± 0.12 Resistant
A/India/1027/2013 H275Y H274Y 185.44 ± 15.95 1,091 HRI 5.30 ± 0.38 Resistant
A/Delaware/08/2011 H275Y H274Y 174.53 ± 21.24 1,027 HRI 4.16 ± 0.73 Resistant
A/Hawaii/67/2014 H275Y H274Y 171.48 ± 31.01 1,009 HRI 4.21 ± 0.58 Resistant
A/Michigan/65/2015 H275Y H274Y 158.76 ± 28.68 934 HRI 5.77 ± 0.22 Resistant
A/Denmark/528/2009 H275Y H274Y 153.26 ± 14.47 902 HRI 5.30 ± 0.26 Resistant
A/Georgia/31/2016 H275Y H274Y 150.48 ± 24.48 885 HRI 5.60 ± 0.19 Resistant
A/Maryland/04/2011 H275Y H274Y 145.64 ± 4.41 857 HRI 5.30 ± 0.53 Resistant
A/Washington/31/2016 H275Y H274Y 141.00 ± 9.58 829 HRI 5.76 ± 0.60 Resistant
A/Texas/23/2012 H275Y H274Y 145.07 ± 30.07 805 HRI 5.48 ± 0.67 Resistant
A/Colorado/30/2015 H275Y H274Y 132.40 ± 32.65 779 HRI 5.84 ± 0.30 Resistant
A/Texas/48/2009 H275Y H274Y 120.22 ± 18.65 707 HRI 3.85 ± 0.19 Resistant
A/Bolivia/1278/2014 I223R I222R 11.68 ± 0.15 65 RI 1.99 ± 0.30 Resistant
A/Tennessee/24/2016 S247R S246R 6.61 ± 0.45 37 RI 5.67 ± 0.47 Resistant
A/India/1819/2016 S247R S246R 6.31 ± 0.09 35 RI 7.58 ± 0.47 Resistant
A/Dnipro/133/2014 S247R S246R 5.66 ± 0.10 31 RI 3.79 ± 0.35 Resistant
A/Chile/1579/2009 I223K I222K 2.84 ± 0.65 16 RI 0.42 ± 0.03 Nonresistant
A/Pennsylvania/05/2016 D199G D198G 1.47 ± 0.03 8 NI 1.03 ± 0.26 Resistant
A/California/12/2012 Controld 0.18 ± 0.06 1 NI 0.24 ± 0.16 Nonresistant
A/Bethesda/956/2006 R292K R292K > 1,000 > 14,285 HRI 7.22 ± 0.24 Resistant
A/Texas/12/2007 E119V E119V 37.92 ± 5.56 542 HRI 1.06 ± 0.11 Resistant
A/Massachusetts/07/2013 E119V E119V 37.33 ± 10.40 533 HRI 1.04 ± 0.04 Resistant
A/Arkansas/13/2013 E119V E119V 34.88 ± 2.69 498 HRI 1.22 ± 0.11 Resistant
A/Illinois/03/2015 E119V E119V 31.98 ± 3.70 458 HRI 1.32 ± 0.14 Resistant
A/Washington/33/2014 E119V E119V 29.83 ± 6.56 426 HRI 1.19 ± 0.08 Resistant
A/Massachusetts/07/2013 Del245–248 Del245–248 21.70 ± 3.59 310 HRI 1.74 ± 0.06 Resistant
A/Washington/01/2007 Control 0.07 ± 0.02 1 NI 0.16 ± 0.07 Nonresistant
B/Victoria lineage
B/Florida/103/2016 A200T A201T 318.19 ± 37.76 23 RI 7.30 ± 0.09 Resistant
B/Bangladesh/3008/2013 E117G E119G 115.54 ± 10.19 8 RI 4.34 ± 0.45 Resistant
B/Laos/1471/2016 N294S N294S 108.37 ± 12.31 8 RI 2.29 ± 0.55 Resistant
B/Mexico/4260/2016 I221V I222V 58.57 ± 9.38 4 NI 2.42 ± 0.03 Resistant
B/Laos/0425/2016 Control 13.99 ± 0.61 1 NI 0.95 ± 0.18 Nonresistant
B/Yamagata lineage
B/Illinois/03/2008 E117A E119A > 1,000 > 112 HRI 10.44 ± 0.26 Resistant
B/Hong Kong/36/2005 R374K R371K > 1,000 > 112 HRI 9.11 ± 0.28 Resistant
B/Memphis/20/1996 R150K R152K 591.47 ± 61.79 66 HRI 3.99 ± 0.36 Resistant
B/Vermont/15/2015 D197N D198N 73.76 ± 8.17 8 RI 2.39 ± 0.18 Resistant
B/Santiago/75552/2015 D197N D198N 54.81 ± 6.48 6 RI 2.59 ± 0.24 Resistant
B/Gorbea/75877/2015 D197N D198N 49.51 ± 8.85 6 RI 2.49 ± 0.03 Resistant
B/Ontario/1110/2011 H273Y H274Y 57.48 ± 6.98 6 RI 1.66 ± 0.16 Nonresistant
B/California/88/2015 H273Y H274Y 50.18 ± 7.58 6 RI 1.78 ± 0.34 Nonresistant
B/Florida/05/2016 K152N K154N 43.59 ± 4.88 5 RI 4.09 ± 0.29 Resistant
B/Utah/15/2016 D197N D198N 38.72 ± 3.19 4 NI 3.06 ± 0.58 Resistant
B/Rochester/02/2001 D197N D198N 37.08 ± 1.96 4 NI 2.40 ± 0.33 Resistante
B/Wisconsin/42/2016 G407S G402S 36.08 ± 3.52 4 NI 1.99 ± 0.10 Nonresistant
B/Rochester/02/2001 Control 8.93 ± 0.82 1 NI 0.97 ± 0.12 Nonresistant

Del: deletion; iART: influenza Antiviral Resistance Test; IC50: inhibitory concentration 50%; R-factor: ratio of chemiluminescent signal intensity generated by viral neuraminidase activity on the substrate, with and without inhibitor (i.e. oseltamivir carboxylate); SD: standard deviation.

a Mean and standard deviation based on the results from at least three independent experiments.

b Criteria for reporting NAI assay results based on an IC50 fold increase compared with the reference IC50 value (control virus): for influenza A, normal (< 10-fold), reduced (10–100-fold) and highly reduced (> 100-fold) inhibition, and for influenza B the same criteria, but using < 5-fold, 5–50-fold and > 50-fold increases [9]; NI, normal inhibition; RI, reduced inhibition; HRI, highly reduced inhibition.

c Output result as shown on the device’s display; result is based on the pre-set cutoffs for influenza A (≥ 0.7) and B (≥ 2.2) viruses.

d Control, a virus lacking NA changes (amino acid substitutions or deletions) associated with altered inhibition by oseltamivir, was included for each antigenic group (type/subtype/lineage) and used to determine a fold change and a degree of inhibition.

e Two results were displayed as resistant and one as nonresistant.

Virus isolates containing a mix of influenza viruses with and without H275Y mutations

In some instances, a sample may contain the drug-resistant and wild-type viruses (mix), but still be detected as normally inhibited in the NAI assay. To assess the ability of iART to detect oseltamivir resistance in such samples, we next tested samples with increasing proportions of H275Y (as determined by pyrosequencing [15]). Notably, isolates containing ≥ 24% of the H275Y variant were identified as resistant by iART, whereas NAI assay required ≥ 52% of the H275Y variant to detect RI, suggesting that iART was more efficient at this task (Table 3).

Table 3

Results from neuraminidase inhibition (NAI) and iART assays on mixtures of influenza A(H1N1)pdm09 viruses containing different proportions of mutants with H275Y in the neuraminidase (n = 22)

Virus Pyrosequencing (%)a NAI assay iART
H275 H275Y IC50, nM (Fold)b Interpretationc R-factor Resultd
A/Louisiana/08/2013 0 100 190.84 (1,004) HRI 5.97 Resistant
A/Mississippi/11/2013 3 97 177.62 (935) HRI 6.67 Resistant
A/North Carolina/04/2014 3 97 199.91 (1,052) HRI 6.17 Resistant
A/Michigan/73/2016 3 97 157.39 (828) HRI 5.89 Resistant
A/Texas/09/2014 7 93 131.02 (690) HRI 5.39 Resistant
A/Texas/100/2013 9 91 150.21 (791) HRI 5.03 Resistant
A/Massachusetts/06/2016 10 90 121.85 (641) HRI 6.03 Resistant
A/Pennsylvania/18/2014 11 89 127.1 (669) HRI 6.20 Resistant
A/Florida/10/2014 14 86 111.35 (586) HRI 6.46 Resistant
A/Colorado/07/2014 16 84 110.24 (580) HRI 6.22 Resistant
A/Brazil/0257 S2/2016 25 75 97.73 (514) HRI 4.92 Resistant
A/Brazil/9061/2014 32 68 39.32 (207) HRI 3.47 Resistant
A/Quebec/RV1424/2016 48 52 4.14 (22) RI 1.93 Resistant
Mix #1e 63 37 1.37 (8) NI 1.09 Resistant
A/Utah/10/2013 68 32 0.98 (5) NI 1.25 Resistant
A/North Carolina/21/2013 72 28 0.95 (5) NI 1.28 Resistant
Mix #2 76 24 0.73 (4) NI 0.71 Resistant
Mix #3 84 16 0.49 (3) NI 0.46 Nonresistant
A/Michigan/36/2016 89 11 0.57 (3) NI 0.43 Nonresistant
Mix #4 92 8 0.37 (2) NI 0.28 Nonresistant
Mix #5 96 4 0.35 (2) NI 0.12 Nonresistant
A/Maryland/08/2013 100 0 0.22 (1) NI 0.18 Nonresistant

iART: influenza Antiviral Resistance Test; IC50: inhibitory concentration 50%; R-factor: ratio of chemiluminescent signal intensity generated by viral neuraminidase activity on the substrate, with and without inhibitor (i.e. oseltamivir carboxylate).

a Proportion of H275 and H275Y virus subpopulations was determined by a single-nt polymorphism (SNP) pyrosequencing analysis in allele quantification mode (AQ) as described in reference [15].

b Fold increase calculated using the median oseltamivir IC50 for influenza A(H1N1)pdm09 viruses circulating during 2015/16 influenza season.

c Interpretation of NAI assay results based on the fold increase in IC50 value: normal (< 10-fold), reduced (10–100-fold) and highly reduced (> 100-fold) inhibition; NI, normal inhibition; RI, reduced inhibition; HRI, highly reduced inhibition.

d Output result as shown on the device’s display; result is based on the pre-set cutoffs for influenza A (≥ 0.7) and influenza B (≥ 2.2) viruses.

e H275 and H275Y mixes were prepared by combining the two virus isolates A/Maryland/08/2013 and A/Louisiana/08/2013, at different ratios.

Influenza virus isolates with mutations other than H275Y

Next, we assessed iART ability to detect influenza viruses harbouring NA mutations other than H275Y and displaying RI/HRI against oseltamivir (Table 2): A(H1N1)pdm09 viruses that displayed RI by oseltamivir carrying the S247R (n = 3) or I223R (n = 1) were identified as resistant with high R-factors for S247R and an R-factor of 1.99 ± 0.30 for I223R. One virus carrying I223K was detected as nonresistant with an R-factor substantially below the resistance threshold (0.42 ± 0.03). The virus carrying D199G displayed NI (eightfold) by NAI assay and was identified as resistant by iART (Table 2). A(H3N2) viruses that display HRI by NAI assay were all identified as resistant by iART. The R-factor of the R292K virus was much greater than those harbouring either E119V or a four-amino acid deletion (del245–248). Three B/Victoria/2/87-lineage viruses – harbouring E117G, N294S or A200T – that displayed RI against oseltamivir were all identified as resistant by iART (Table 2). B/Yamagata/16/98-lineage viruses harbouring E117A, R150K or R374K, that displayed HRI by NAI assay were identified as resistant; and two viruses carrying H273Y and one carrying G407 presenting borderline NI/RI were identified as nonresistant by iART (Table 2). Finally, a group of viruses from both B/lineages – carrying D197N, K152N and I221V – showed borderline NI/RI by NAI assay (4–8-fold), and these viruses were identified as resistant by iART. These results demonstrate that iART may detect some influenza viruses harbouring NA changes in the enzyme active site (e.g. D199G in A(H1N1)pdm09 and I221V in type B) that otherwise would be classified as NI by oseltamivir using NAI assay. Notably, the criteria to separate viruses exhibiting NI from those with RI is arbitrary [9], and can be refined as more data become available. The interpretation of results obtained for viruses displaying borderline IC50 should be made cautiously.

Testing of clinical specimens

Because iART was designed to detect oseltamivir-resistant viruses in human respiratory specimens, we next tested a set of 64 well-characterised specimens collected during a clinical study conducted in 2008–2010 [16] (Table 4). All the clinical specimens containing pre-pandemic A(H1N1) viruses harbouring H275Y (n = 32) were consistently identified as resistant with a mean R-factor of 6.86 ± 1.31. All other specimens were identified as nonresistant (Table 4). As expected, specimens negative for influenza (n = 10) displayed a signal below the level of detection (data not shown). These results serve as a proof-of-principle that iART can successfully detect oseltamivir-resistant H275Y viruses directly in clinical specimens.

Table 4

Respiratory specimens from the clinical study on the efficacy of treatment with oseltamivir tested using iARTa (n = 64)

Type and subtype Number of specimens Ctb iART/R-factor iART/resultc
A(H1N1) H275Yd 32 24.40 ± 2.63 6.8 6 ± 1.31 Resistant
A(H1N1)pdm09 12 21.31 ± 3.25 0.06 ± 0.02 Nonresistant
A(H3N2) 10 21.75 ± 2.13 0.25 ± 0.11 Nonresistant
B 10 24.46 ± 1.81 0.99 ± 0.10 Nonresistant

Ct: cycle threshold; iART: influenza Antiviral Resistance Test; R-factor: ratio of chemiluminescent signal intensity generated by viral neuraminidase activity on the substrate, with and without inhibitor (i.e. oseltamivir carboxylate).

a Aliquots of leftover respiratory specimens (nasal or nasopharyngeal wash) from the clinical study [13] were used for testing by iART. Specimens were initially processed on ice in the laboratory within the study clinic. The study was reviewed and approved by the ethics and research review board of the International Centre for Diarrheal Diseases, Bangladesh (icddr,b) and the institutional review board of the United States Centers for Disease Control and Prevention (CDC). All index patients provided written informed consent. Clinical specimens were aliquoted and stored at -70 °C until testing using real-time reverse-transcriptase PCR assay (rRT-PCR), pyrosequencing (to detect neuraminidase amino acid substitutions previously associated with oseltamivir resistance), virus isolation and neuraminidase inhibition assay testing. All respective virus isolates, except those carrying H275Y, displayed normal inhibition in the NAI assay. For testing using iART, 0.5 mL of clinical specimen was used; all specimens tested underwent a single freeze/thaw cycle.

b Ct value as determined using rRT-PCR assay according to the CDC protocols.

c Output result as shown on the device’s display; result is based on the pre-set cutoffs for influenza A (≥ 0.7) and B (≥ 2.2) viruses.

d Pre-pandemic A(H1N1) carrying H275Y, straight neuraminidase amino acid numbering.

Of note, the recommended volume for the iART test in its current configuration is 0.5 mL of sample, which is often unavailable at surveillance laboratories. Moreover, clinical specimens submitted to surveillance laboratories commonly undergo freeze-thaw cycles before testing, which adversely affect the integrity of virus particles. To address these concerns, we next tested a set of residual clinical specimens from the 2015/16 US national surveillance that were previously confirmed influenza virus positive; only 0.1 mL of each specimen was used for testing using iART. Of 85 tested, 17 samples (20%) had a signal below the limit of detection; 59 samples (69%) were identified as nonresistant; and nine samples (11%) as resistant (Table 5). These nine harboured H275Y, E119V or K152N. The matching isolates of these nine clinical specimens displayed RI/HRI in the NAI assay, while the other virus isolates showed NI.

Table 5

Residual clinical specimens from the 2015/16 United States national influenza surveillance tested using iART (n = 85)

Type and subtype Number of specimens testeda Number of. indeterminateb Number of nonresistantc Number of resistantc NA mutation in resistant virusesd
A(H1N1)pdm09 34 9 19 6 H275Y
A(H3N2) 25 5 18 2 E119V
B 26 3 22 1 K152N
Total 85 17 59 9 Not applicable

NA: neuraminidase.

a Leftovers of clinical specimens submitted for United States national virological surveillance that satisfied the following criteria: (i) NA sequencing or pyrosequencing data were available; (ii) virus was recovered in cell culture and tested using NAI assay. For testing using iART, 0.1 mL of a residual clinical specimen was combined with 0.4 mL of viral transport medium (VTM, Becton Dickinson) to bring the final volume to 0.5 mL.

b Indeterminate: specimen displayed a low signal to noise ratio (SNR); insufficient NA activity for testing.

c Output result as shown on the device’s display; result is based on the pre-set cutoffs for influenza A (≥ 0.7) and B (≥ 2.2) viruses.

d Position of amino acid residue shown using straight NA numbering (Table 1).


A limitation of this study is that the effect of viral loads in relation to the performance of iART was not investigated. As the iART detects NA activity, one challenge is the difference in NA specific activities of seasonal wild-type viruses, whereby the minimal viral load needed for the iART assay may depend on the virus type/subtype and might not be generalisable. More studies are needed to establish the type/subtype specific limit of detection. Moreover, NA mutations that confer oseltamivir resistance may or may not affect the NA specific activity, so the influence of this on viral load appropriate for the assay would also have to be investigated independently for such viruses.

Taken together, however, the data presented here show that the iART assay can become a valuable tool for surveillance laboratories. iART offers a fast mean for detecting viruses displaying RI/HRI against oseltamivir in either isolates or clinical specimens. It is a simple approach where signal measurement, data analysis and interpretation are done by a compact portable device. The assay robustness is evident from its ability to test specimens under less than optimal conditions (i.e. interference from virus transport media (VTM), multiple freeze/thaw cycles, limited volume). Although iART is not a substitute for NAI assay employed by specialised laboratories, it has great potential to enable a broader adoption of influenza antiviral resistance testing in various settings.

The prototype of the iART system tested in this study was configured by the developers for surveillance applications to detect viruses that could be identified by the gold standard NAI assay. Of note, samples collected by surveillance laboratories may be stored in a variety of storage media (e.g. VTM). To accommodate various types of sample media, the current iART workflow includes a buffer exchange to remove media components that interfere with the assay. If this assay is to be used at clinical care settings, this step is not needed, since a buffer optimised for the iART assay can be used for sample collection.

Larger studies are desirable to provide a better understanding of the performance and utility of the iART assay and to establish laboratory correlates (e.g. R-factor threshold) for clinically-relevant resistance. As iART was designed to test influenza A viruses, regardless of their antigenic subtype, the utility of this rapid test in detecting oseltamivir resistance in zoonotic influenza viruses (e.g. avian A(H7N9)) needs to be evaluated, as this would facilitate pandemic preparedness. Nonetheless, we are confident that the implementation of this assay, which is available for national public health agencies, e.g. the US CDC and application by its network of influenza surveillance laboratories, can facilitate timely detection of oseltamivir resistance emergence and spread.


Financial support. This work was partially supported by the Department of Health and Human Services; Office of the Assistant Secretary for Preparedness and Response (HHS/ASPR); Biomedical Advanced Research and Development Authority (BARDA) under Contract no. HHSO100201300008C.

The authors are grateful to US public health laboratories and members of the International Centre for Diarrhoeal Disease Research (Dhaka, Bangladesh) for providing influenza viruses. We also thankful to ISRV-AVG for providing the NAI susceptibility reference panel of influenza viruses. We appreciate valuable technical assistance of Juan De La Cruz (Battelle, USA), Anton Chesnokov (CDC, USA), and Patricia Jorquera (Chickasaw Nation Industries Advantage, USA).

Disclaimer: The findings and conclusions of this report are those of the authors and do not necessarily represent the views of the funding institutions.

Conflict of interest

EF, KW and RJ are employees of Becton Dickinson.

Authors’ contributions

Designed the study: LVG, KW. Generated and analysed antiviral susceptibility data: VPM, EF and EH. Generated sequencing data: JB. Clinical data analysis and interpretation: AMF and AB. Drafted the article: LVG and KW. Revised the article: WK, LVG and KW. Provided supervisory oversight: DEW, RJ and RS. All authors further edited the manuscript and approved the final version of the paper.


  1. Oh DY, Hurt AC. A Review of the Antiviral Susceptibility of Human and Avian Influenza Viruses over the Last Decade.Scientifica (Cairo). 2014;2014:430629. DOI: 10.1155/2014/430629 PMID: 24800107

  2. Samson M, Pizzorno A, Abed Y, Boivin G. Influenza virus resistance to neuraminidase inhibitors.Antiviral Res. 2013;98(2):174-85. DOI: 10.1016/j.antiviral.2013.03.014 PMID: 23523943

  3. Takashita E, Kiso M, Fujisaki S, Yokoyama M, Nakamura K, Shirakura M,  et al.  Characterization of a large cluster of influenza A(H1N1)pdm09 viruses cross-resistant to oseltamivir and peramivir during the 2013-2014 influenza season in Japan. Antimicrob Agents Chemother. 2015;59(5):2607-17. DOI: 10.1128/AAC.04836-14 PMID: 25691635

  4. Okomo-Adhiambo M, Fry AM, Su S, Nguyen HT, Elal AA, Negron E,  et al. , 2013–14 US Influenza Antiviral Working Group. Oseltamivir-resistant influenza A(H1N1)pdm09 viruses, United States, 2013-14.Emerg Infect Dis. 2015;21(1):136-41. DOI: 10.3201/eid2101.141006 PMID: 25532050

  5. Hurt AC, Hardie K, Wilson NJ, Deng YM, Osbourn M, Leang SK,  et al.  Characteristics of a widespread community cluster of H275Y oseltamivir-resistant A(H1N1)pdm09 influenza in Australia. J Infect Dis. 2012;206(2):148-57. DOI: 10.1093/infdis/jis337 PMID: 22561367

  6. Matsuzaki Y, Mizuta K, Aoki Y, Suto A, Abiko C, Sanjoh K,  et al.  A two-year survey of the oseltamivir-resistant influenza A(H1N1) virus in Yamagata, Japan and the clinical effectiveness of oseltamivir and zanamivir. Virol J. 2010;7(1):53. DOI: 10.1186/1743-422X-7-53 PMID: 20202225

  7. Kawai N, Ikematsu H, Hirotsu N, Maeda T, Kawashima T, Tanaka O,  et al.  Clinical effectiveness of oseltamivir and zanamivir for treatment of influenza A virus subtype H1N1 with the H274Y mutation: a Japanese, multicenter study of the 2007-2008 and 2008-2009 influenza seasons. Clin Infect Dis. 2009;49(12):1828-35. DOI: 10.1086/648424 PMID: 19911968

  8. Nguyen HT, Fry AM, Gubareva LV. Neuraminidase inhibitor resistance in influenza viruses and laboratory testing methods.Antivir Ther. 2012;17(1 Pt B):159-73. DOI: 10.3851/IMP2067 PMID: 22311680

  9. Meetings of the WHO working group on surveillance of influenza antiviral susceptibility – Geneva, November 2011 and June 2012. Wkly Epidemiol Rec. 2012;87(39):369-74.PMID: 23061103

  10. Meijer A, Rebelo-de-Andrade H, Correia V, Besselaar T, Drager-Dayal R, Fry A,  et al.  Global update on the susceptibility of human influenza viruses to neuraminidase inhibitors, 2012-2013. Antiviral Res. 2014;110:31-41. DOI: 10.1016/j.antiviral.2014.07.001 PMID: 25043638

  11. Takashita E, Meijer A, Lackenby A, Gubareva L, Rebelo-de-Andrade H, Besselaar T,  et al.  Global update on the susceptibility of human influenza viruses to neuraminidase inhibitors, 2013-2014. Antiviral Res. 2015;117:27-38. DOI: 10.1016/j.antiviral.2015.02.003 PMID: 25721488

  12. Thompson CI, Lackenby A, Daniels RS, McCauley JW, Pereyaslov D, Broberg EK,  et al.  Evaluation of influenza virus antiviral susceptibility testing in Europe: results from the first external quality assessment exercise. J Clin Virol. 2013;56(3):212-8. DOI: 10.1016/j.jcv.2012.11.005 PMID: 23201459

  13. Okomo-Adhiambo M, Mishin VP, Sleeman K, Saguar E, Guevara H, Reisdorf E,  et al.  Standardizing the influenza neuraminidase inhibition assay among United States public health laboratories conducting virological surveillance. Antiviral Res. 2016;128:28-35. DOI: 10.1016/j.antiviral.2016.01.009 PMID: 26808479

  14. Marjuki H, Mishin VP, Sleeman K, Okomo-Adhiambo M, Sheu TG, Guo L,  et al.  Bioluminescence-based neuraminidase inhibition assay for monitoring influenza virus drug susceptibility in clinical specimens. Antimicrob Agents Chemother. 2013;57(11):5209-15. DOI: 10.1128/AAC.01086-13 PMID: 23917311

  15. Tamura D, DeBiasi RL, Okomo-Adhiambo M, Mishin VP, Campbell AP, Loechelt B,  et al.  Emergence of Multidrug-Resistant Influenza A(H1N1)pdm09 Virus Variants in an Immunocompromised Child Treated With Oseltamivir and Zanamivir. J Infect Dis. 2015;212(8):1209-13. DOI: 10.1093/infdis/jiv245 PMID: 25943200

  16. Fry AM, Goswami D, Nahar K, Sharmin AT, Rahman M, Gubareva L,  et al.  Efficacy of oseltamivir treatment started within 5 days of symptom onset to reduce influenza illness duration and virus shedding in an urban setting in Bangladesh: a randomised placebo-controlled trial. Lancet Infect Dis. 2014;14(2):109-18. DOI: 10.1016/S1473-3099(13)70267-6 PMID: 24268590

Back to Table of Contents
Download (pdf)

The publisher’s policy on data collection and use of cookies.

Disclaimer: The opinions expressed by authors contributing to Eurosurveillance do not necessarily reflect the opinions of the European Centre for Disease Prevention and Control (ECDC) or the editorial team or the institutions with which the authors are affiliated. Neither ECDC nor any person acting on behalf of ECDC is responsible for the use that might be made of the information in this journal. The information provided on the Eurosurveillance site is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her physician. Our website does not host any form of commercial advertisement. Except where otherwise stated, all manuscripts published after 1 January 2016 will be published under the Creative Commons Attribution (CC BY) licence. You are free to share and adapt the material, but you must give appropriate credit, provide a link to the licence, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

Eurosurveillance [ISSN] - ©2007-2016. All rights reserved

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:
verify here.