Kat Kelley

The US Department of Health and Human Services has published new rules intended to improve compliance to a 2007 law intended to increase the public availability of clinical trial data. The law requires researchers to register and share data from clinical trials, grants the US Food and Drug Administration (FDA) the authority to fine pharmaceutical companies up to US$10,000 per day for failure to register or report results, and allows the US National Institutes of Health (NIH) to refuse to disburse funds to noncompliant grantees. Between 2008 and 2015, violations of the law warranted more than $25 billion in fines, however, no such fines have been issued to date. Many advocates have expressed concern that the new rules are only as effective as their enforcement. Neither the FDA nor the NIH plan to hire additional staff to enforce compliance of the law. Facebook CEO Mark Zuckerberg and his wife Dr. Priscilla Chan have committed US$3 billion over the next ten years to “cure, prevent, or manage all disease.” The couple is investing $600 million to launch the “Biohub” at the University of California, San Francisco, which will convene scientists and engineers, supporting collaboration in research and product development. The Biohub’s first two ventures are ambitious: the Cell Atlas, which will involve the characterization of every type of cell found in the human body, and the Infectious Disease Initiative, which will support research and development (R&D) for drugs, diagnostics, and vaccines against infectious diseases. The Initiative will establish a Rapid Response Team with the ability to rapidly mobilize scientists and accelerate R&D during an outbreak. The mosquito-borne Mayaro virus, primarily found in the Amazon, has been reported in Haiti. The symptoms of Mayaro—fever and joint pain—are similar to chikungunya, however, the pain can last for nearly a year and patients often report abdominal pain as well. The virus, which was identified in a blood sample taken from a child suffering from the illness, varied from the strain responsible for the more than 40 cases reported in South America since its discovery in 1954. Researchers are particularly concerned with the presence of Mayaro in the Caribbean in light of the ongoing outbreak of Zika virus, which was discovered several decades ago but has only recently begun to spread rapidly and have a significant health impact. A new report from the World Bank quantifying the economic impact of antimicrobial resistance (AMR) indicates that by 2050, the impact of AMR on the global economy and in particular, the livestock industry, could push nearly 30 million people into extreme poverty. Further, drug-resistant infections are much more difficult and costly to treat, and thus, AMR could increase health spending by $1 trillion per year by 2050. These findings reveal that AMR could have a much greater economic impact than the 2008 financial crisis, particularly for low- and middle-income countries. Gonorrhea, a sexually transmitted infection resulting in nearly 90 million new infections each year, has grown increasingly resistant to antibiotics. A new cluster of cases in Hawaii suggests that the emergence of untreatable strains of the bacteria are closer than ever. Over time, gonorrhea has developed resistance to several common antibiotics including penicillin, tetracycline, and fluoroquinolones; the current treatment, a combination of the antibiotics azithromycin and ceftriaxone, is considered the last resort. The samples identified in Hawaii showed unprecedented levels of resistance to azithromycin and burgeoning resistance to ceftriaxone. While azithromycin and ceftriaxone are the only remaining drugs that are effective against the bacteria and well tolerated by humans, scientists at Louisiana State University are testing a new oral antibiotic that appeared to be safe and effective against gonorrhea in phase 2 clinical trials.

Scientists have devised a Trojan horse strategy to prevent the Ebola virus from infecting human cells. To infect humans, the virus binds to the surface of a human cell, enters the cell, and then binds to the protein Niemann-Pick C1 (NPC1). Once it binds to NPC1, the virus can start replicating and spreading throughout the body. Consequently, the researchers first engineered two antibodies: one that targets the human protein NPC1 and another that targets the viral protein that binds to NPC1. However, they needed a Trojan horse: a molecule that could deliver the antibodies to the scene of the crime, deep inside human cells, where the virus binds to NPC1. The solution? The team synthesized each antibody with a third antibody that binds to the surface of the Ebola virus. In short, the team created two molecules by combining the antibody that could latch onto the virus with two antibodies that could prevent the virus from infecting human cells. Both combinations proved effective in the lab against all five strains of the Ebola virus and in mouse trials, one of the molecules effectively treated infected mice. Next, the molecules will be tested in nonhuman primates. A recent piece in STAT takes an in-depth look at the critical advances in hepatitis C research that paved the way for the development of Sovaldi, the first drug proven to cure hepatitis C. Hepatitis C was first discovered in 1989, however, the virus is notoriously difficult to reproduce in the lab. Consequently, the time and cost of producing the virus hindered research. Ralf Bartenschlager and Charles Rice, researchers at the University of Heidelberg and Rockefeller University, respectively, determined that certain mutations of the virus enabled select strains of the virus to survive in the lab, and engineered versions of the virus—deemed “replicons”—with those mutations. Using these replicons, drug companies were able to rapidly screen the efficacy of different compounds in combatting hepatitis C. Among these companies, the small biotech firm Pharmasset developed a particularly promising drug, which was eventually—after the company was acquired by Gilead Sciences—approved and marketed as Sovaldi. The drug became the first cure for Hepatitis C, however, its price tag of up to US$94,000 for the full regimen has impeded access to it. While existing evidence suggests that Zika infection has the greatest impact on fetal brain development during the first trimester of pregnancy, new research indicates that infection later in pregnancy can still have a devastating impact. Scientists at the University of Washington infected a pregnant monkey with the virus at the beginning of her third trimester, and in less than a month, significant damage to the fetus was reported: both the white matter in the brain and the head itself stopped growing. However, the team administered the virus in higher doses than would be found in individual mosquitoes, and researchers at the University of Wisconsin-Madison, who used lower doses, found no fetal brain damage after infecting four pregnant monkeys.

The US National Institutes of Health (NIH) announced the Antimicrobial Resistance Diagnostic Challenge last week, a competition which will award US$20 million for the development of rapid, point-of-care diagnostics to combat antimicrobial resistance. The competition will be funded by NIH's National Institute of Allergy and Infectious Diseases and the US Department of Health and Human Services’ Biomedical Advanced Research and Development Authority, while the US Centers for Disease Control and Prevention and the US Food and Drug Administration will provide scientific and regulatory expertise. Eligible diagnostics are those that either test for drug-resistant bacteria or differentiate between viral and bacterial infections, critical tools to reduce ineffective and unnecessary antibiotic prescriptions. The recently launched Coalition for Epidemic Preparedness Innovations (CEPI) will fund early stage human clinical trials and stockpile vaccine candidates for the viruses most likely to cause the next major epidemic. CEPI will collaborate with product developers and the World Health Organization (WHO) to facilitate regulatory review of vaccine candidates and to ensure that large scale clinical trials can be rapidly rolled out in the case of an outbreak. Eligible vaccine candidates will target viruses identified by the WHO as the greatest threats, including Crimean Congo hemorrhagic fever, Ebola and Marburg, Lassa fever, Rift Valley fever, Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS), and Nipah virus. The coalition was formed by the governments of India and Norway, philanthropic organizations the Wellcome Trust and the Bill & Melinda Gates Foundation, and the World Economic Forum and will be housed at the Norwegian Institute for Public Health in Oslo. The International Vaccine Institute (IVI) is partnering with Xiamen Innovax Biotech Co., Ltd. (Innovax) to expand access to the world’s first and only vaccine against Hepatitis E—a viral disease that causes 20 million infections and results in 70,000 deaths and 3,000 stillbirths each year. The vaccine, Hecolin®, was developed by Innovax and is only licensed for use in China. The Gates Foundation will support an assessment of the vaccine to determine its eligibility for WHO prequalification—a process that evaluates the safety, efficacy, and quality of a specific health tool produced by a specific manufacturer and that enables the product to be purchased by United Nations agencies. Hecolin® offered complete protection against hepatitis E in a phase 3 clinical trial with more than 100,000 participants. Pharmaceutical company Takeda has initiated a phase 3 clinical trial of its vaccine candidate against dengue fever, a mosquito-borne infection caused by four closely related viruses. Last year, pharmaceutical company Sanofi launched the world’s first dengue vaccine, however, new research suggests that the vaccine could actually increase the severity of infections in children who have never been exposed to dengue. This is due to antibody-dependent enhancement, in which protective antibodies against a virus (in this case, one strain of dengue virus) can actually help related viruses (the other three strains of dengue virus) attack human cells. Consequently, the antibodies produced by children receiving the vaccine could actually exacerbate the symptoms of future infections. In phase 1 and 2 trials, Takeda’s vaccine candidate appeared to be safe and resulted in the production of antibodies against all four strains of the virus. For its phase 3 trial, Takeda plans to enroll 20,000 children in dengue-endemic nations in Latin America and Asia. The trial will evaluate safety and efficacy against all four strains of dengue and in children with and without prior exposure to the virus.

The Toxoplasma gondii parasite is infamous for consuming brain tissue, causing brain cancer, and even altering the behavior of infected individuals. However, new research suggests that it could be modified and used to treat ovarian cancer. The team of scientists at Dartmouth University created a weakened version of T. gondii, removing the genes that enable the parasite to take over its host’s cells. Next, mice with aggressive ovarian cancer were inoculated with the weakened parasite. The study demonstrated that the presence of T. gondii, along with certain proteins excreted by the parasite, resulted in an enhanced immune response to ovarian cancer tumors. While none of the mice were completely cured—which could in part be attributable to the late stage of cancer at the time of treatment—those treated with the weakened parasite survived an additional 40 days on average. The World Health Organization (WHO) has issued new treatment guidelines for chlamydia, gonorrhea, and syphilis, as the three sexually transmitted infections (STIs) grow increasingly resistant to antibiotics. While resistant strains of chlamydia and syphilis are rare, multidrug-resistant gonorrhea has emerged in at least ten countries, and resistance to six classes of antibiotics has been reported. The WHO is calling for enhanced surveillance of drug-resistant strains of gonorrhea, and recommends that national treatment guidelines be determined based on local patterns of resistance. While syphilis is curable with a single dose of benzathine penicillin, the supply of the drug is low, and stock outs have been reported in a number of countries. While early stages of these three STIs are often asymptomatic, they can cause significant long-term damage, including pelvic inflammatory disease and infertility. Furthermore, they can be transmitted from mother-to-child during pregnancy and childbirth, and can increase the risk of ectopic pregnancy, miscarriage, stillbirth, and newborn death. As bacteria grow resistant to antibiotics, so too do fungi to antifungals. Each year, fungal infections result in 1 million deaths, and strains of both the aspergillus and candida fungi are growing resistant to the azole class of antifungals. While there are more than 20 classes of antibiotics, there are only four classes of antifungals, and thus, resistance to just one class of medicines is a major cause for concern. Scientists believe the leading cause of fungal resistance is the widespread use of fungicides on crops and in certain household paints and coatings. While dissecting mosquitoes in Guaico, Trinidad, researchers at the US Army Medical Research Institute of Infectious Diseases discovered a new and bewildering virus, configured unlike any other virus known to infect animals. Most viruses are comprised of a handful of genes packaged into one particle, however, the five genes of Guaico Culex exist as independent particles, and can only infect a mosquito if at least four of the five are present. Previously, viruses with this structure—known as multicomponent genomes—had only been found in plants and fungi. While humans are not susceptible to Guiaco Culex, a related virus has been found in monkeys, indicating that another multicomponent virus could infect humans.

In this regular feature on Breakthroughs, we highlight some of the most interesting reads in global health research from the past week. In this edition, we cover new insights into the impact of the Zika virus on the brain. Researchers have released medical images of 46 fetuses and infants born to women who were infected with the Zika virus during pregnancy, revealing serious brain damage beyond microcephaly. The images, which include 23 MRI scans, 41 CT scans, and 93 ultrasounds, were taken at Instituto de Pesquisa in Campina Grande State Paraiba in northeastern Brazil and analyzed by neurologists at the Instituto in partnership with a team at the Beth Israel Deaconess Medical Center in Boston. The brain damage manifests in distinct ways: many of the scans showed skulls filled with cerebrospinal fluid, and in one case there was so little brain tissue that the skull collapsed in on itself, resulting in a flattened skull with extra skin. The images indicated damage to the brain stem, which regulates breathing and heart rate; the cerebellum, which is responsible for motor control; and the cortex, which is involved for learning, memory, emotion, and language. New research suggests that Hofbauer cells, found in the placenta and tasked with protecting the fetus from pathogens, may be the key to the Zika virus' ability to cross the maternal-fetal barrier. Hofbauer cells are macrophages, immune cells that combat pathogens by consuming them. However, dengue virus—a flavivirus related to Zika—is able to hijack macrophages, using them to replicate and disseminate throughout the body. While the researchers have confirmed that the Zika virus is able to survive within Hofbauer cells, they suspect that the immune cells may also be enabling the virus to travel to the fetal brain. The study also confirms that the virus can replicate within fibroblasts, a critical component of the placenta’s structure, a finding described as, “a bit of a surprise,” by one of the study’s authors. Scientists at Rockefeller University have also described their recent findings as "kind of a surprise," in this case, that certain adult brain cells are also susceptible to the virus. Fetal brains are primarily comprised of neural progenitor cells; while these stems cells are not as ubiquitous in adults, they play a critical role in learning and memory. Earlier this year, researchers determined that fetal neural progenitor cells are particularly vulnerable to Zika. Now, the team at Rockefeller has confirmed that adult neural progenitor cells are no exception. The study revealed an increase in cell death but a decrease in the production of new brain cells in infected adult mice. More research is needed to determine how this translates to humans, however, such damage could increase risk for cognitive challenges, depression, and Alzheimer’s disease.

Penicillin, the world’s first antibiotic, works by targeting certain proteins—appropriately named penicillin-binding proteins (PBPs)—that play a critical role in building and maintaining the bacterial cell wall. Now, scientists at Harvard Medical School have identified another class of proteins which play a similar role and could be a target for the next generation of antibiotics. The road to discovery started in 2003, when it was determined that certain bacteria could grow without PBPs. In their absence, the proteins responsible for maintaining cell wall shape, elongation, division, and spore formation (SEDS proteins) continued to function normally, enabling the bacteria to thrive. SEDS proteins are found in more types of bacteria than PBPs, and consequently a treatment targeting SEDS proteins could have even broader application than penicillin. On February 22, the Obama Administration requested US$1.9 billion in emergency funding for the Zika response, and 181 days later, Congress has yet to approve it. Consequently, the Department of Health and Human Services (HHS) has shifted $81 million from other programs to support Zika vaccine research and development—$34 million of which will go to the National Institutes of Health (NIH) and $47 million of which will be allocated to the Biomedical Advanced Research and Development Authority (BARDA). Earlier this year, HHS repurposed $589 million in funding from the Ebola response to combat Zika, however, that funding will run out by the end of this month. The NIH will use its funding for human clinical trials of its leading Zika vaccine candidate, however, the agency will need an additional $196 million for additional trials and to advance a second and third candidate. BARDA’s funding will enable the agency to secure contracts and establish partnerships for Zika vaccine development, however, an additional $342 million will be required to continue its work. New research suggests that infection with the Plasmodium parasite, which causes malaria, could reduce the severity of Ebola infection. A team of scientists at the US National Institute of Allergy and Infectious Diseases has examined 1,868 blood samples from an Ebola treatment unit in Liberia—1,182 of which tested positive for Ebola—concluding that patients co-infected with malaria were 20 percent more likely to survive. These results held true even when controlling for the patient’s age and viral load. Viral load actually correlated with survival rates: those with the highest levels of Plasmodium had an 83 percent survival rate, compared to 46 percent of those only infected with Ebola. At the treatment center, all patients were provided with antimalarials, and consequently, treatment for malaria was not responsible for survival rates. While the reason for this trend remains a mystery, Drs. Emmie de Wit and Kyle Rosenke—the study’s lead scientists—suspect that an existing malaria infection expedites the immune response to Ebola, consequently increasing survival rates.