An Increasing Danger of Zoonotic Orthopoxvirus Infections

On May 8, 1980, the World Health Assembly at its 33^rd session solemnly declared that the world and all its peoples had won freedom from smallpox and recommended ceasing the vaccination of the population against smallpox. Currently, a larger part of the world population has no immunity not only against smallpox but also against other zoonotic orthopoxvirus infections. Recently, recorded outbreaks of orthopoxvirus diseases not only of domestic animals but also of humans have become more frequent. All this indicates a new situation in the ecology and evolution of zoonotic orthopoxviruses. Analysis of state-of-the-art data on the phylogenetic relationships, ecology, and host range of orthopoxviruses—etiological agents of smallpox (variola virus, VARV), monkeypox (MPXV), cowpox (CPXV), vaccinia (VACV), and camelpox (CMLV)—as well as the patterns of their evolution suggests that a VARV-like virus could emerge in the course of natural evolution of modern zoonotic orthopoxviruses. Thus, there is an insistent need for organization of the international control over the outbreaks of zoonotic orthopoxvirus infections in various countries to provide a rapid response and prevent them from developing into epidemics.The genus Orthopoxvirus of the family Poxviridae comprises the species variola (smallpox) virus (VARV), with human as its only sensitive host; zoonotic species monkeypox virus (MPXV), cowpox virus (CPXV), vaccinia virus (VACV), and camelpox virus (CMLV); and several others. These orthopoxviruses are immunologically cross-reactive and cross-protective, so that infection with any member of this genus provides protection against infection with any other member of the genus [1], [2]. Traditionally, the species of the Orthopoxvirus genus have been named primarily according to the host animal from which they were isolated and identified based on a range of biological characteristics [1]. Most frequently, zoonotic orthopoxviruses have been initially isolated from animals immediately close to humans being incidental hosts for the virus, the natural carriers of which are, as a rule, wild animals. Correspondingly, the name of an orthopoxvirus species does not reflect the actual animal that is its natural reservoir.With accumulation of the data on complete genome nucleotide sequences for various strains of orthopoxvirus species, it has been found that an interesting feature of the orthopoxvirus genomes is the presence of genes that are intact in one species but fragmented or deleted in another [3]–[8]. These data confirm the concept of a reductive evolution of orthopoxviruses, according to which the gene loss plays an important role in the evolutionary adaptation of progenitor virus to a particular environmental niche (host) and emergence of new virus species [9]. CPXV has the largest genome of all the modern representatives of the genus Orthopoxvirus, and this genome contains all the genes found in the other species of this genus [2], [4], [10]–[12]. Therefore, Cowpox virus was proposed as the closest of all the modern species to the progenitor virus for the genus Orthopoxvirus, while the remaining species, Variola virus included, had appeared as a result of multistage reductive evolution [4], [9], [13].VARV, the most pathogenic species for humans, has the smallest genome of all the orthopoxviruses [2]–[7]. This suggests a potential possibility for emergence of a VARV-like variant from the currently existing zoonotic orthopoxviruses with longer genomes in the course of natural evolution. It is known that although mutational changes are rather a rare event for the poxvirus DNA [13], characteristic of these viruses is the possibility of intermolecular and intramolecular recombinations, as well as genomic insertions and deletions [14], [15]. It has been recently found that duplication/amplification of genomic segments is typical of poxviruses, and in the case of a certain selective pressure (for example, host antiviral defenses), certain genes are able to relatively rapidly accumulate mutations that would provide the virus adaptation to new conditions, including a new host [16].The conducted analysis of the available archive data on smallpox and the history of ancient civilizations as well as the newest data on the evolutionary relationships of orthopoxviruses has allowed me to suggest the hypothesis that smallpox could have repeatedly emerged in the past via evolutionary changes of a zoonotic progenitor virus [17].Because of the cessation of the vaccination against smallpox after its eradication 35 years ago, a tremendous part of the world human population currently has no immunity not only against smallpox, but also against any other zoonotic orthopoxvirus infections. This new situation allows orthopoxviruses to circulate in the human population and, as a consequence, should alter several established concepts on the ecology and range of sensitive hosts for various orthopoxvirus species.The most intricate case is the origin of VACV. For many decades, VACV has been used for vaccinating humans against smallpox, and it was considered that this virus, variolae vaccinae, originates from zoonotic CPXV, introduced to immunization practice by Jenner as early as 1796 [1]. Only in the 20^th century was it found out that the orthopoxvirus strains used for smallpox vaccination significantly differ in their properties from both the natural CPXV isolates recovered from cows and the other orthopoxvirus species examined by that time [18]. Correspondingly, they were regarded as a separate species, Vaccinia virus [19]. Moreover, it was inferred that the VACV natural reservoir was unknown and numerous hypotheses attempted to explain the origin of this virus while passaging progenitor viruses in animals in the process of vaccine production [1], [2], [20].The issue of VACV origin was somewhat clarified after sequencing the complete genome of horsepox virus (HSPV) [21], which appeared to be closely related to the sequenced VACV strains. Only after this was attention paid to the fact that Jenner specified the origin of his vaccine from an infection of the heels of horses (“grease”) and indicated that the vaccine became more suitable for human use after passage through the cow [20]. This suggests that VACV may originate from a zoonotic HSPV, which naturally persisted concurrently with CPXV. Some facts suggest that the infectious materials not only from cow lesions but also from horse lesions were used for smallpox vaccination in the 19^th century. The vaccine lymph from the horse gave the most satisfactory results in inducing an anti-smallpox immunity as well as less side reactions [1]. By all accounts, they gradually commenced using HSPV isolates for smallpox vaccination, the future generations of which recovered decades later were ascribed to the separate species Vaccinia virus [19], rather than CPXV for smallpox vaccination everywhere.Since the 1960s, VACVs have been repeatedly isolated in Brazil [22]. The first VACV isolates were recovered from wild rodents (sentinel mice and rice rat) [23]. Since 1999, an ever-increasing number of exanthematous outbreaks affecting dairy cows and their handlers have been recorded [24]–[27], supplemented recently with outbreaks among horses [28], [29]. Several VACV strains have been isolated during these outbreaks from cows, horses, humans, and rodents [22], [27], [28], [30], [31]. The questions that arise are when and how VACV entered Brazil and the wild nature of the American continent. The more widespread point of view is that VACV strains could be transmitted from vaccinated humans to domestic animals and further to wild ones with subsequent adaptation to the rural environment [22]. My standpoint implies that HSPV/VACV could have been repeatedly accidentally imported from Europe to South America with the infected horses or rodents to be further introduced into wildlife. Possibly, the latter hypothesis more adequately reflects the actual pathway of VACV transmission to the Brazilian environment, since recent phylogenetic studies have suggested an independent origin for South American VACV isolates, distinct from the vaccine strains used on this continent during the WHO smallpox eradication campaign [22], [32]. Presumably, genome-wide sequencing of the viruses will give a more precise answer to the origin of VACV variants isolated in Brazil.In the past, the outbreaks of buffalopox had occurred frequently in various states of India as well as in Pakistan, Bangladesh, Indonesia, Egypt, and other countries [33]. The causative agent, buffalopox virus (BPXV), is closely related to VACV and affiliated with the species Vaccinia virus, genus Orthopoxvirus [2], [34]. Recently, mass outbreaks of buffalopox in domestic buffaloes along with severe zoonotic infection in milk attendants were recorded at various places in India [35], [36]. In several buffalopox outbreaks, the BPXV-caused infections were recorded in cows in the same herds [37]. An increase in BPXV transmission to different species, including buffaloes, cows, and humans, suggests the reemergence of zoonotic buffalopox infection [35], [38]. The buffalopox outbreaks recorded in different distant regions of India are likely to suggest the presence of an abundant natural BPXV reservoir represented by wild animals, most probably rodents. Correspondingly, it is of the paramount importance to perform a large-scale study of the presence of orthopoxviruses in wild animals of India.Thus, yet incomplete data on the modern ecology of VACV and BPXV allow for speculation that the orthopoxviruses belonging to the species Vaccinia virus have a wide host range, are zoonotic, are currently spread over large areas in Eurasia and South America, and that their natural carriers are several rodents.CPXV has relatively low pathogenicity for humans but has a wide range of sensitive animal hosts [2], [39]. Human cowpox is a rare sporadic disease, which develops when CPXV is transmitted from an infected animal to human [2], [40]. This disease is mainly recorded in Europe. In wildlife, CPXV carriers are asymptomatically infected rodents [41], [42]. During the last two decades, reports on an increasing number of CPXV infections in cats, rats, exotic animals, and humans have been published [43]–[47]. Comparative studies of the properties of CPXV isolates recovered from various hosts at different times and in several geographic zones have shown sufficient intraspecific variations [2], [48], [49]. A recent phylogenetic analysis of the complete genomes of 12 CPXV strains recovered from humans and several animal species suggests that they be split into two major Cowpox virus–like and Vaccinia virus–like clades [50]. This means that the criteria of the separation of orthopoxviruses into these two species should be corrected.MPXV is a zoonotic virus causing a human infection similar to smallpox in its clinical manifestations with a lethality rate of 1–8% [51]. The natural reservoir of MPXV is various species of African rodents [8], [10]. The active surveillance data in the same health zone (Democratic Republic of Congo) from the 1980s to 2006–2007 suggest a 20-fold increase in human monkeypox incidence 30 years after the cessation of the smallpox vaccination campaign [52]. This poses the question of whether MPXV can acquire the possibility of a high human-to-human transmission rate, characteristic of VARV, under conditions of a long-term absence of vaccination and considerably higher incidence of human infection. If this occurs, humankind will face a problem considerably more complex than with the smallpox eradication. First and foremost, this is determined by the fact that MPXV, unlike VARV, has its natural reservoir represented by numerous African rodents [2], [53].In its biological properties and according to the data of phylogenetic analysis of the complete virus genomic sequence, CMLV is closest to VARV, the causative agent of smallpox, as compared with the other orthopoxvirus species [1], [8]. Camelpox is recognized as one of the most important viral diseases in camels. This infection was first described in India in 1909. Subsequently, camelpox outbreaks have been reported in many countries of the Middle East, Asia, and Africa [54], [55]. Until recently, it has been commonly accepted that the host range of CMLV is confined to one animal species, camels [1], [55]. However, the first human cases of camelpox have been recently confirmed in India [56]. This suggests that camelpox could be a zoonotic disease. Since camelpox outbreaks occur irregularly in distant regions of the world and the viruses isolated during these outbreaks display different degrees of virulence [55], it is possible to postulate the presence of a wildlife animal reservoir of CMLV other than camels. Since the camelpox outbreaks are usually associated with the rainy season of the year, when rodents are actively reproducing, it is likely that rodents could be the natural carriers of CMLV.It is known that most of the emerging human pathogens originate from zoonotic pathogens [57]–[59]. Many viruses do not cause the disease in their natural reservoir hosts but can be highly pathogenic when transmitted to a new host species. Emerging and reemerging human pathogens more often are those with broad host ranges. The viruses able to infect many animal species are evolutionarily adapted to utilizing different cell mechanisms for their reproduction and, thus, can extend/change their host range with a higher probability [58].There are no fundamental prohibitions for the possible reemergence of smallpox or a similar human disease in the future as a result of natural evolution of the currently existing zoonotic orthopoxviruses. An ever-increasing sensitivity of the human population to zoonotic orthopoxviruses, resulting from cessation of the mass smallpox vaccination, elevates the probability for new variants of these viruses, potentially dangerous for humans, to emerge. However, the current situation is radically different from the ancient one, since many outbreaks of orthopoxvirus infections among domestic animals and humans are recorded and studied.Recently, the efforts of scientists under WHO control are directed to the development of state-of-the-art methods for VARV rapid identification as well as design of new generation safe smallpox vaccines and drugs against VARV and other orthopoxviruses [60]. The designed promising anti-orthopoxvirus drugs display no pronounced virus species specificity. Therefore, they are applicable in the outbreaks caused by any orthopoxvirus species. International acceptance of the designed highly efficient anti-orthopoxvirus drugs ST-246 and CMX001 [60] is of paramount importance.In the areas of high incidence of zoonotic orthopoxviral infections, it would be purposeful to vaccinate domestic and zoo animals as well as the persons closely associated with them using state-of-the-art safe vaccines based on VACV, which has a wide range of sensitive hosts. This would considerably decrease the likelihood for such infections to spread from wildlife into the human environment.In the African region endemic for monkeypox, which also displays a high rate of HIV infection, the population could be vaccinated with the VACV strain MVA, which has been recently demonstrated to be safe even for HIV-infected persons [61].Taking into account the above mentioned increased incidence of outbreaks of animal and human orthopoxvirus infections and their potential danger, it is important to accelerate organization of the international Smallpox Laboratory Network, discussed by the WHO Advisory Committee on Variola Virus Research [62], [63], and orient this network to express diagnosing not only of VARV but also of other zoonotic orthopoxviruses. This will provide constant monitoring of these infections in all parts of the world and make it possible to prevent the development of small outbreaks into expanded epidemics, thereby decreasing the risk of evolutional changes and emergence of an orthopoxvirus highly pathogenic for humans.The international system for clinical sampling and identification of infectious agents has been worked out and optimized while implementing the global smallpox eradication program under the aegis of the WHO as well as anti-epidemic measures and methods for mass vaccination [1]. The accumulated experience is of paramount importance for the establishment of international control not only over currently existing orthopoxvirus infections but also other emerging and reemerging diseases.     

Advances and gaps in SARS-CoV-2 infection models

The global response to Coronavirus Disease 2019 (COVID-19) is now facing new challenges such as vaccine inequity and the emergence of SARS-CoV-2 variants of concern (VOCs). Preclinical models of disease, in particular animal models, are essential to investigate VOC pathogenesis, vaccine correlates of protection and postexposure therapies. Here, we provide an update from the World Health Organization (WHO) COVID-19 modeling expert group (WHO-COM) assembled by WHO, regarding advances in preclinical models. In particular, we discuss how animal model research is playing a key role to evaluate VOC virulence, transmission and immune escape, and how animal models are being refined to recapitulate COVID-19 demographic variables such as comorbidities and age.

In February of 2020, the World Health Organization (WHO) R&D Blueprint convened a group of experts to develop preclinical models of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. Since its inception, the goal of this WHO COVID Modeling group (WHO-COM) has been to accelerate the development of Coronavirus Disease 2019 (COVID-19) vaccines and therapeutics by rapidly sharing data among member scientists worldwide. In addition, concerns were raised at that time about the possibility of vaccine-associated enhanced respiratory disease (VAERD) or antibody-dependent enhancement (ADE) after vaccination or infection. In September of 2020, the WHO-COM published a review on COVID-19 animal models [1], which reflected the state-of-the art at that time, with the vast majority of publications authored by members of the group.Preclinical studies in nonhuman primates (NHPs) of COVID-19 vaccines that are currently being deployed [2–5] proved remarkably predictive of the outcome of clinical efficacy studies. In particular, NHP studies not only predicted high clinical efficacy of these vaccines but also suggested immune correlates of protection. Moreover, preclinical studies accurately predicted that protection against severe pneumonia would be easier to achieve than protection against viral replication in nasal mucosa. These observations confirm the value and importance of the use of animal models for COVID-19.In 2021, with several vaccines rolling out worldwide and the detection of variants of concern (VOCs), the development of preclinical models of SARS-CoV-2 infection and their role in COVID-19 research has entered into a new phase. This paper provides an update from the WHO-COM regarding advances in preclinical models. In particular, we discuss how animal model research has provided insight into VOC pathogenesis and correlates of protection and has helped therapeutic development. Finally, we discuss the current status of VAERD research and the race to develop models that recapitulate COVID-19 demographic variables such as comorbidities and age.     

Viral OTU Deubiquitinases: A Structural and Functional Comparison

Recent studies have revealed that proteases encoded by three very diverse RNA virus groups share structural similarity with enzymes of the Ovarian Tumor (OTU) superfamily of deubiquitinases (DUBs). The publication of the latest of these reports in quick succession prevented proper recognition and discussion of the shared features of these viral enzymes. Here we provide a brief structural and functional comparison of these virus-encoded OTU DUBs. Interestingly, although their shared structural features and substrate specificity tentatively place them within the same protease superfamily, they also show interesting differences that trigger speculation as to their origins.The covalent attachment of ubiquitin (Ub) to protein substrates, i.e., ubiquitination, plays a pivotal regulatory role in numerous cellular processes [1]–[5]. Ubiquitination can be reversed by deubiquitinases (DUBs) [6] and, not surprisingly, various virus groups encode such DUBs to influence ubiquitin-mediated host cell processes [7]–[21]. Some of these viral DUBs resemble proteases belonging to the Ovarian Tumor (OTU) superfamily [22]–[28]. Makarova et al. previously identified OTU proteases as a novel superfamily of cysteine proteases from different organisms [29], and their bioinformatics-based analysis included several of the viral enzymes discussed here. Recently reported structures of these viral DUBs include the OTU domains of the nairoviruses Crimean-Congo hemorrhagic fever virus (CCHFV) [22]–[24] and Dugbe virus (DUGV) [25], the papain-like protease (PLP2) domain of the arterivirus equine arteritis virus (EAV) [26], and the protease (PRO) domain of the tymovirus turnip yellow mosaic virus (TYMV) (Figure 1A–1D) [27], [28]. These viruses are strikingly diverse, considering that nairoviruses are mammalian negative-strand RNA viruses, while the mammalian arteriviruses and plant tymoviruses belong to separate orders of positive-strand RNA viruses.Open in a separate windowFigure 1Viral and eukaryotic OTU domain structures and viral protein context.Crystal structures of (A) CCHFV OTU (3PT2) [23], (B) DUGV OTU (4HXD) [25], (C) EAV PLP2 (4IUM) [26], (D) TYMV PRO (4A5U) [27], [28], (E) yeast OTU1 (3BY4) [57], and (F) human OTUD3 (4BOU) [46]. The β-hairpin motifs of CCHFV OTU and DUGV OTU are indicated in boxes in panels A and B, respectively, and the zinc-finger motif of EAV PLP2 is boxed in panel C. Active sites are indicated with arrows. The CCHFV OTU, DUGV OTU, EAV PLP2, and yeast OTU1 domains were crystallized in complex with Ub, which has been removed for clarity. Structure images were generated using PyMol [60]. (G) Schematic representation of the CCHFV large (L) protein [61], [62]. A similar organization is found in the DUGV L protein, but is not depicted. The OTU domain resides in the N-terminal region of this protein and is not involved in autoproteolytic cleavage events [48]. (H) Schematic representation of the EAV polyprotein 1ab [63]. PLP2 resides in nonstructural protein 2 (nsp2) and is responsible for the cleavage between nsp2 and nsp3 [51]. (I) Schematic representation of the TYMV ORF1 polyprotein [50]. PRO resides in the N-terminal product of this polyprotein and is responsible for two internal cleavages [49], [50]. Key replicative enzymes are indicated in G, H, and I. Colored arrowheads denote cleavage sites for the indicated protease domains. HEL, helicase; PLP, papain-like protease; RdRp, RNA-dependent RNA polymerase; SP, serine protease.Ubiquitination often involves the formation of polyubiquitin chains [1], which can target the ubiquitinated substrate to the proteasome for degradation [2] or modulate its protein–protein interactions, as in the activation of innate immune signaling pathways [3], [4]. Interestingly, several cellular OTU DUBs were found to negatively regulate innate immunity [30]–[33]. Likewise, both nairovirus OTU and arterivirus PLP2 were recently shown to inhibit innate immune responses by targeting ubiquitinated signaling factors [7]–[9], [26], [34], [35]. In contrast to eukaryotic OTU DUBs, both of these viral proteases were found to also deconjugate the Ub-like protein interferon-stimulated gene 15 (ISG15) [7], [36], which inhibits viral replication via a mechanism that is currently poorly understood [37]. Interestingly, coronaviruses (which, together with the arteriviruses, belong to the nidovirus order) also encode papain-like proteases targeting both Ub and ISG15 that were shown to inhibit innate immunity [11]–[13], [38]–[42] but belong to the ubiquitin-specific protease (USP) class of DUBs [6], [43], [44]. The presence of functionally similar, yet structurally different proteases in distantly related virus families highlights the potential benefits to the virus of harboring such enzymes.The proteasomal degradation pathway is an important cellular route to dispose of viral proteins, as exemplified by the turnover of the TYMV polymerase [45]. Moreover, the degradation of this protein is specifically counteracted by the deubiquitinase activity of TYMV PRO, which thus promotes virus replication [10]. The functional characterization of viral OTU DUBs remains incomplete and future studies will likely reveal additional roles in replication and virus–host interplay.Polyubiquitin chains can adopt a number of different configurations, depending on the type of covalent linkage present within the polymer [1]. A distal Ub molecule can be linked via its C-terminus to one of seven internal lysine residues present in a proximal Ub molecule via an isopeptide bond. Alternatively, in the case of linear chains, the C-terminus of the distal Ub is covalently linked to the N-terminal methionine residue of the proximal Ub via a peptide bond. While human OTU proteases often show a distinct preference for one or two isopeptide linkage types [46], nairovirus OTUs and TYMV PRO appear to be more promiscuous in their substrate preference [22], [25]. However, like most human OTU proteases, they seem unable to cleave linear polyubiquitin chains in vitro [22], [25], [46]. Arterivirus PLP2 has not been extensively studied in this respect.It is important to note that many positive-strand RNA viruses, including arteriviruses and tymoviruses, encode polyproteins that are post-translationally cleaved by internal protease domains [47]. Thus, while CCHFV OTU is not involved in viral protein cleavage and its activity seems dispensable for replication (Figure 1G) [48], both arterivirus PLP2 and tymovirus PRO are critically required for viral replication due to their primary role in polyprotein maturation (Figure 1H, 1I) [49]–[53]. Interestingly, while both EAV PLP2 and TYMV PRO can process peptide bonds in cis and in trans [50], [51], PRO does not cleave peptide bonds in linear polyubiquitin chains in vitro [25]. To date, activity of EAV PLP2 towards linear polyubiquitin chains has not been reported.Based on mutagenesis of putative catalytic residues, arterivirus PLP2 and tymovirus PRO were initially generally classified as papain-like cysteine proteases [51], [54], [55]. Now that crystal structures of these proteases are available, it is possible to search the DALI server [56] in order to identify structurally similar domains. Using the 3-dimensional coordinates of TYMV PRO, the most recently solved structure of a viral OTU protease, such a query identifies structural similarity with eukaryotic OTU DUBs as well as the nairovirus OTU domains and EAV PLP2 ([57] further highlights their similarities (Figure 2A–2C), and these comparisons together clearly position them within the OTU DUB superfamily. Sequence comparisons alone were insufficient to demonstrate this conclusively, as the similarity of viral OTU domains to each other and to eukaryotic OTU proteases is very limited and mostly restricted to the areas surrounding the active site residues [29].Open in a separate windowFigure 2Superpositions of the viral OTU proteases with yeast OTU1 and one another.Superpositions of yeast OTU1 (3BY4) [57] with (A) CCHFV OTU (3PT2) [23], RMSD: 1.8 Å over 112 residues, (B) EAV PLP2 (4IUM) [26], RMSD: 2.8 Å over 69 residues, and (C) TYMV PRO (4A5U) [27], [28], RMSD: 1.4 Å over 76 residues. Superpositions of the yeast OTU1-Ub complex with (D) the CCHFV OTU-Ub complex and (E) the EAV PLP2-Ub complex, highlighting the difference in the orientation of Ub between the two viral OTU domains versus the eukaryotic yeast OTU1 domain. The Ub that is complexed with yeast OTU1 is depicted in yellow, while the Ub complexed with CCHFV OTU or EAV PLP2 is depicted in orange. (F) Superposition of EAV PLP2 and TYMV PRO, RMSD: 2.5 Å over 53 residues. (G) Close-up of the active site region (boxed) of the superposition depicted in F. Side chains of the catalytic cysteine (Cys270 and Cys783 for EAV PLP2 and TYMV PRO, respectively) and histidine (His332 and His869 for EAV PLP2 and TYMV PRO, respectively) residues are shown as sticks, as well as the active site Asn263 for EAV PLP2. The backbone amide group of Asp267 likely contributes to the formation of the oxyanion hole in the active site of EAV PLP2, yet a functionally equivalent residue is absent in TYMV PRO. The Gly266 and Gly268 residues flanking Asp267 in EAV PLP2 are depicted as sticks as well, for clarity. Note the alternative orientation of the active site cysteine residue of TYMV PRO which, unlike EAV PLP2, was not determined in covalent complex with an Ub suicide substrate. All alignments were generated using the PDBeFOLD server [64], and thus the reported RMSD values differ from those reported in [60]. RMSD, root-mean-square deviation.

Table 1

Three-dimensional structural alignment of viral OTU domains against selected structures in the Protein Data Bank using the DALI server [56].

The Role of Genomics in Tracking the Evolution of Influenza A Virus

Influenza A virus causes annual epidemics and occasional pandemics of short-term respiratory infections associated with considerable morbidity and mortality. The pandemics occur when new human-transmissible viruses that have the major surface protein of influenza A viruses from other host species are introduced into the human population. Between such rare events, the evolution of influenza is shaped by antigenic drift: the accumulation of mutations that result in changes in exposed regions of the viral surface proteins. Antigenic drift makes the virus less susceptible to immediate neutralization by the immune system in individuals who have had a previous influenza infection or vaccination. A biannual reevaluation of the vaccine composition is essential to maintain its effectiveness due to this immune escape. The study of influenza genomes is key to this endeavor, increasing our understanding of antigenic drift and enhancing the accuracy of vaccine strain selection. Recent large-scale genome sequencing and antigenic typing has considerably improved our understanding of influenza evolution: epidemics around the globe are seeded from a reservoir in East-Southeast Asia with year-round prevalence of influenza viruses; antigenically similar strains predominate in epidemics worldwide for several years before being replaced by a new antigenic cluster of strains. Future in-depth studies of the influenza reservoir, along with large-scale data mining of genomic resources and the integration of epidemiological, genomic, and antigenic data, should enhance our understanding of antigenic drift and improve the detection and control of antigenically novel emerging strains.Influenza is a single-stranded, negative-sense RNA virus that causes acute respiratory illness in humans. In temperate regions, winter influenza epidemics result in 250,000–500,000 deaths per year; in tropical regions, the burden is similar [1],[2]. Influenza viruses of three genera or types (A, B, and C) circulate in the human population. Influenza viruses of the types B and C evolve slowly and circulate at low levels. Type A evolves rapidly and can evade neutralization by antibodies in individuals who have been previously infected with, or vaccinated against, the virus. As a result it regularly causes large epidemics. Furthermore, distinct reservoirs of influenza A exist in other mammals and in birds. Four times in the last hundred years these reservoirs have provided genetic material for novel viruses that have caused global pandemics [3]–[8].The genome of influenza A viruses comprises eight RNA segments of 0.9–2.3 kb that together span approximately 13.5 kb and encode 11 proteins [9]. Segment 4 encodes the major surface glycoprotein called hemagglutinin (H), which is responsible for attaching the virus to sialic acid residues on the host cell surface and fusing the virus membrane envelope with the host cell membrane, thus delivering the viral genome into the cell (Figure 1). Segment 6 encodes another surface glycoprotein called neuraminidase (N), which cleaves terminal sialic acid residues from glycoproteins and glycolipids on the host cell surface, thus releasing budding viral particles from an infected cell [10]. Influenza A viruses are further classified into distinct subtypes based on the genetic and antigenic characteristics of these two surface glycoproteins. Sixteen hemagglutinin (H1–16) and nine neuraminidase subtypes (N1–9) are known to exist, and they occur in various combinations in influenza viruses endemic in aquatic birds [10],[11]. Viruses with the subtype composition H1N1 and H3N2 have been circulating in the human population for several decades. Of these two subtypes, H3N2 evolves more rapidly, and has until recently caused the majority of infections [1],[12],[13]. In the spring of 2009, however, a new H1N1 virus originating from swine influenza A viruses, and only distantly related to the H1N1 already circulating, gained hold in the human population. The emergence of this virus has initiated the first influenza pandemic of the twenty-first century [7],[14],[15].Open in a separate windowFigure 1Schematic representation of an influenza A virion.Three proteins, hemagglutinin (HA, a trimer of three identical subunits), neuraminidase (NA, a tetramer of four identical subunits), and the M2 transmembrane proton channel (a tetramer of four identical subunits), are anchored in the viral membrane, which is composed of a lipid bilayer. The large, external domains of hemagglutinin and neuraminidase are the major targets for neutralizing antibodies of the host immune response. The M1 matrix protein is located below the membrane. The genome of the influenza A virus is composed of eight individual RNA segments (conventionally ordered by decreasing length, bottom row), which each encode one or two proteins. Inside the virion, the eight RNA segments are packaged in a complex with nucleoprotein (NP) and the viral polymerase complex, consisting of the PA, PB1, and PB2 proteins.Hemagglutinin is about five times more abundant than neuraminidase in the viral membrane and is the major target of the host immune response [16]–[18]. Following exposure to the virus, whether by infection or vaccination, the host immune system acquires the capacity to produce neutralizing antibodies against the viral surface glycoproteins. These antibodies participate in clearing an infection and may protect an individual from future infections for many decades [19]. Five exposed regions on the surface of hemagglutinin, called epitope sites, are predominantly recognized by such antibodies [16],[17]. However, the human subtypes of influenza A continuously evolve and acquire genetic mutations that result in amino acid changes in the epitopes. These changes reduce the protective effect of antibodies raised against previously circulating viral variants. This “antigenic drift” necessitates frequent modification and readministration of the influenza vaccine to ensure efficient protection (Box 1).

Box 1. Broadly Protective Vaccines

Current influenza vaccines are based on detergent-inactivated viruses. They elicit antibodies with a narrow range of protection that target predominantly the variable regions of the hemagglutinin protein. Accordingly, the seasonal influenza vaccine includes one strain with segments of the surface proteins for each of the A/H1N1, A/H3N2 and B viruses, and it is updated every 1–3 years to match the predominant variants of influenza. Research into vaccines that offer broader protection across diverse subtypes and antigenic drift variants is ongoing [21], [59]–[61]. This research is particularly important with respect to the emergence of novel viruses with pandemic potential, such as the 2009 H1N1 virus. In such an event, the time period between the detection of the virus and the onset of a pandemic is too short to produce a specific vaccine for immediate vaccination of the population. Work in this area is focused on developing vaccines that elicit antibodies against conserved viral components, such as certain regions of hemagglutinin, neuraminidase, and the M2 proton channel in the viral membrane [60]. Other types of vaccines based on live attenuated viruses or plasmid DNA expression vectors, or supplemented with adjuvants, show promise in inducing a more broadly protective immune response [61].To monitor for novel emerging strains, the World Health Organization (WHO) maintains a global surveillance program. A panel of experts meets twice a year to review antigenic, genetic, and epidemiological data and decides on the vaccine composition for the next winter season in the northern or southern hemisphere [20]. If an emerging antigenic variant is detected and judged likely to become predominant, an update of the vaccine strain is recommended. This “predict and produce” approach mostly results in efficient vaccines that substantially limit the morbidity and mortality of seasonal epidemics [21]. The recommendation has to be made almost a year before the season in which the vaccine is used, however, because of the time required to produce and distribute a new vaccine. Problems arise when an emerging variant is not identified early enough for an update of the vaccine composition [22]–[24]. Thus, gaining a detailed understanding of the evolution and epidemiology of the virus is of the utmost importance, as it may lead to earlier identification of novel emerging variants [20].The development of high-throughput sequencing has recently provided large datasets of high-quality, complete genome sequences for viral isolates collected in a relatively unbiased manner, regardless of virulence or other unusual characteristics [9],[25]. Analyses of the genome sequence data combined with large-scale antigenic typing [26],[27] have given insights into the pattern of global spread, the genetic diversity during seasonal epidemics, and the dynamics of subtype evolution. Influenza data repositories such as the NCBI Influenza Virus Resource (http://www.ncbi.nlm.nih.gov/genomes/FLU/FLU.html) [28] and the Global Initiative on Sharing All Influenza Data (GISAID; http://platform.gisaid.org/) database [29] make the genomic information publicly available, together with epidemiological data for the sequenced isolates. The GISAID model for data sharing requires users to agree to collaborate with, and appropriately credit, all data contributors. A notable success of this initiative has been the contribution of countries, such as Indonesia and China, which have previously been reticent about placing data in the public domain. The WHO also supports the endeavor of rapid publication of all available sequences for influenza viruses and there is hope that comprehensive submission to public databases will soon become a reality [24],[30]. In the future, mining these resources and establishing a statistical framework based on epidemiological, antigenic, and genetic information could provide further insights into the rules that govern the emergence and establishment of antigenically novel variants and improve the potential for influenza prevention and control.     

LipidII: Just Another Brick in the Wall?

Nearly all bacteria contain a peptidoglycan cell wall. The peptidoglycan precursor molecule is LipidII, containing the basic peptidoglycan building block attached to a lipid. Although the suitability of LipidII as an antibacterial target has long been recognized, progress on elucidating the role(s) of LipidII in bacterial cell biology has been slow. The focus of this review is on exciting new developments, both with respect to antibacterials targeting LipidII as well as the emerging role of LipidII in organizing the membrane and cell wall synthesis. It appears that on both sides of the membrane, LipidII plays crucial roles in organizing cytoskeletal proteins and peptidoglycan synthesis machineries. Finally, the recent discovery of no less than three different categories of LipidII flippases will be discussed.Peptidoglycan (PG), the main component of the cell wall, is a structure unique to bacteria. Currently, over 50% of the antibiotics in use target bacterial cell wall synthesis, and thus PG synthesis is considered the Achilles’ heel of bacteria [1]. The precursor of PG is LipidII, a lipid-linked disaccharide with a pentapeptide side chain. Linkage of the disaccharide to a growing glycan strand results in release of the lipid anchor and leaves the pentapeptide free for crosslinking to peptides on other glycan strands or for processing. Various excellent reviews describe the synthesis of LipidII, the incorporation of LipidII into PG, and the use of LipidII as a target for antibacterials [2–6]. LipidII’s conserved structure makes it difficult for pathogens to develop resistance against LipidII targeting molecules. This review focuses on the latest findings on antibacterials targeting LipidII, such as teixobactin [7], and on new LipidII biology (summarized in Fig 1). It is becoming more and more evident that LipidII is not just a passive brick that is being added to the cell wall but rather plays a key role in organization of the membrane.Open in a separate windowFig 1Organization of cell wall synthesis by LipidII.Overview of recent work that highlights various new insights about the role of LipidII; for example, (1) in the identification of novel antibacterials that target LipidII (including teixobactin and bacteriocins), (2) how LipidII is translocated over the membrane by different families of flippases (such as FtsW or RodA, MurJ, and Amj), (3) how it is recruited to regions of increased fluidity (RIFs) and how it organizes attachment of MreB(-like) filaments, and (4) how cell wall synthesis enzymes (penicillin-binding proteins [PBPs]) are recruited to LipidII.     

Learning from the COVID-19 pandemic to strengthen routine immunization systems

Kate Causey and Jonathan F Mosser discuss what can be learnt from the observed impacts of the COVID-19 pandemic on routine immunisation systems.

In the final months of 2021, deaths due to the Coronavirus Disease 2019 (COVID-19) surpassed 5 million globally [1]. Available data suggest that even this staggering figure may be a substantial underestimate of the true toll of the pandemic [2]. Beyond mortality, it may take years to fully quantify the direct and indirect impacts of the COVID-19 pandemic such as disruptions in preventive care services. In an accompanying research study in PLOS Medicine, McQuaid and colleagues report on the uptake of routine childhood immunizations in 2020 in Scotland and England during major pandemic-related lockdowns [3]. This adds to a growing body of literature quantifying the impact of the COVID-19 pandemic on routine health services and childhood immunization [4,5], which provides important opportunities to learn from early pandemic experiences as immunization systems face ongoing challenges.McQuaid and colleagues compared weekly or monthly data on vaccine uptake in Scotland and England from January to December of 2020 to the rates observed in 2019 to estimate the changes in uptake before, during, and after COVID-19 pandemic lockdowns in each country. The authors included 2 different preschool immunizations, each with multiple doses. They found significantly increased uptake within 4 weeks of eligibility during the lockdown and postlockdown periods in Scotland for all 5 vaccine dose combinations examined: During lockdown, percentage point increases ranged from 1.3% to 14.3%. In England, there were significant declines in uptake during the prelockdown, lockdown, and postlockdown periods for all 4 vaccine dose combinations examined. However, declines during lockdown were small, with percentage point decreases ranging from −0.5% to −2.1%. Due to the nature of the data available, the authors were unable to account for possible seasonal variation in vaccine delivery, control for important individual-level confounders or effect modifiers such as child sex and parental educational attainment, or directly compare outcomes across the 2 countries.These findings stand in contrast to the documented experience of many other countries, where available data suggest historic disruptions in routine childhood vaccination coverage, particularly during the first months of pandemic-related lockdowns [5,6]. Supply side limitations such as delayed shipments of vaccines and supplies [7], inadequate personal protective equipment [8], staff shortages [9], and delayed or canceled campaigns and introductions [9] threatened vaccine delivery. Furthermore, fear of exposure to COVID-19 at vaccination centers [10], misinformation about vaccine safety [8], and lockdown-related limitations on travel to facilities [9,10] reduced demand. In polls of country experts conducted by WHO, UNICEF, and Gavi, the Vaccine Alliance throughout the second quarter of 2020, 126 of 170 countries reported at least some disruption to routine immunization programs [10,11]. Global estimates suggest that millions more children missed doses of important vaccines than would have in the absence of the COVID-19 pandemic [5,6]. While many vaccine programs showed remarkable resilience in the second half of 2020, with rates of vaccination returning to or even exceeding prepandemic levels [5,6], disruptions to immunization services persisted into 2021 in many countries [12].As the authors discuss, it is critical to pinpoint the specific program policies and strategies that contributed to increased uptake in Scotland and only small declines in England and, more broadly, to the rapid recovery of vaccination rates observed in many other countries. McQuaid and colleagues cite work suggesting that increased flexibility in parental working patterns during lockdowns, providing mobile services or public transport to vaccine centers, and sending phone- and mail-based reminders are strategies that may have improved uptake of timely vaccination in Scotland during this period [13]. Similarly, immunization programs around the world have employed a broad range of strategies to maintain or increase vaccination during the pandemic. Leaders in Senegal, Paraguay, and Sri Lanka designed and conducted media campaigns to emphasize the importance of childhood immunization even during lockdown [8,14,15]. Although many programs delayed mass campaigns in the spring of 2020, multiple countries were able to implement campaigns by the summer of 2020 [8,16–20]. In each of these examples, leaders responded quickly to meet the unique challenges presented by the COVID-19 pandemic in their communities.Increased data collection and tracking systems are essential for efficient and effective responses as delivery programs face challenges. When concern arose for pandemic-related disruptions to immunization services, public health decision-makers in Scotland and England responded by increasing the frequency and level of detail in reports of vaccine uptake and by making these data available for planning and research. The potential for robust data systems to inform real-time decision-making is not limited to high-income countries. For instance, the Nigerian National Health Management Information System released an extensive online dashboard shortly after the onset of the pandemic, documenting the impact of COVID-19 on dozens of indicators of health service uptake, including 16 related to immunization [21]. Vaccination data systems that track individual children and doses, such as the reminder system in Scotland, allow for highly targeted responses. Similarly, in Senegal, Ghana, and in Karachi, Pakistan, healthcare workers have relied on existing or newly implemented tracking systems to identify children who have missed doses and provide text message and/or phone call reminders [8,22,23]. Investing in robust routine data systems allows for rapid scale-up of data collection, targeted services to those who miss doses, and a more informed response when vaccine delivery challenges arise.Policy and program decision-makers must learn from the observed impacts of the COVID-19 pandemic on health systems and vaccine delivery. The study by McQuaid and colleagues provides further evidence that vaccination programs in England and Scotland leveraged existing strengths and identified novel strategies to mitigate disruptions and deliver vaccines in the early stages of the pandemic. However, the challenges posed by the pandemic to routine immunization services continue. To mitigate the risk of outbreaks of measles and other vaccine-preventable diseases, strategies are needed to maintain and increase coverage, while ensuring that children who missed vaccines during the pandemic are quickly caught up. The accompanying research study provides important insights into 2 countries where services were preserved—and even increased—in the early pandemic. To meet present and future challenges, we must learn from early pandemic successes such as those in Scotland and England, tailor solutions to improve vaccine uptake, and strengthen data systems to support improved decision-making.     

Achieving global equity for COVID-19 vaccines: Stronger international partnerships and greater advocacy and solidarity are needed

Peter Figueroa and co-authors advocate for equity in the worldwide provision of COVID-19 vaccines.

Many may not be aware of the full extent of global inequity in the rollout of Coronavirus Disease 2019 (COVID-19) vaccines in response to the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic. As of June 20, 2021, only 0.9% of those living in low-income countries and less than 10% of those in low- and middle-income countries (LMICs) had received at least 1 dose of a COVID-19 vaccine compared with 43% of the population living in high-income countries (HICs) [1] (Fig 1). Only 2.4% of the population of Africa had been vaccinated compared with 41% of North America and 38% of Europe [1,2] (S1 Fig). Primarily due to the inability to access COVID-19 vaccines, less than 10% of the population in as many as 85 LMICs had been vaccinated compared with over 60% of the population in 26 HICs [1]. Only 10 countries account for more than 75% of all COVID-19 vaccines administered [3]. This striking and ongoing inequity has occurred despite the explicit ethical principles affirming equity of access to COVID-19 vaccines articulated in WHO SAGE values framework [4,5] prepared in mid-2020, well prior to the availability of COVID-19 vaccines.Open in a separate windowFig 1Proportion of people vaccinated with at least 1 dose of COVID-19 vaccine by income (April 14 to June 23, 2021).Note: Data on China appeared on the database on June 9, hence the jump in upper middle-income countries. COVID-19, Coronavirus Disease 2019. Source: https://ourworldindata.org/covid-vaccinations.The COVID-19 pandemic highlights the grave inequity and inadequacy of the global preparedness and response to serious emerging infections. The establishment of the Coalition for Epidemic Preparedness Innovations (CEPI) in 2018, the Access to COVID-19 Tools Accelerator (ACT-A), and the COVID-19 Vaccines Global Access (COVAX) Facility in April 2020 and the rapid development of COVID-19 vaccines were all positive and extraordinary developments [6]. The COVAX Facility, as of June 2021, has delivered approximately 83 million vaccine doses to 75 countries, representing approximately 4% of the global supply, and one-fifth of this was for HICs [7]. The COVAX Facility has been challenged to meet its supply commitments to LMICs due to insufficient access to doses of COVID-19 vaccines with the prerequisite WHO emergency use listing (EUL) or, under exceptional circumstances, product approval by a stringent regulatory authority (SRA) [8,9]. Because of the anticipated insufficient COVID-19 vaccine supply through the COVAX Facility, the majority of nonvaccine-producing LMIC countries made the decision, early in the COVID-19 pandemic, to secure and use vaccines produced in China or Russia prior to receipt of WHO EUL or SRA approval. Most of the vaccines used in LMICs as of June 20, 2021 (nearly 1.5 billion doses of the 2.6 billion doses administered) were neither WHO EUL or SRA approved at the time they were given [10]. This may raise possible concerns with respect to the effectiveness, safety, and acceptability of individual vaccines used by many countries [8,9].     

Immunological Mechanisms Mediating Hantavirus Persistence in Rodent Reservoirs

Hantaviruses, similar to several emerging zoonotic viruses, persistently infect their natural reservoir hosts, without causing overt signs of disease. Spillover to incidental human hosts results in morbidity and mortality mediated by excessive proinflammatory and cellular immune responses. The mechanisms mediating the persistence of hantaviruses and the absence of clinical symptoms in rodent reservoirs are only starting to be uncovered. Recent studies indicate that during hantavirus infection, proinflammatory and antiviral responses are reduced and regulatory responses are elevated at sites of increased virus replication in rodents. The recent discovery of structural and non-structural proteins that suppress type I interferon responses in humans suggests that immune responses in rodent hosts could be mediated directly by the virus. Alternatively, several host factors, including sex steroids, glucocorticoids, and genetic factors, are reported to alter host susceptibility and may contribute to persistence of hantaviruses in rodents. Humans and reservoir hosts differ in infection outcomes and in immune responses to hantavirus infection; thus, understanding the mechanisms mediating viral persistence and the absence of disease in rodents may provide insight into the prevention and treatment of disease in humans. Consideration of the coevolutionary mechanisms mediating hantaviral persistence and rodent host survival is providing insight into the mechanisms by which zoonotic viruses have remained in the environment for millions of years and continue to be transmitted to humans.Hantaviruses are negative sense, enveloped RNA viruses (family: Bunyaviridae) that are comprised of three RNA segments, designated small (S), medium (M), and large (L), which encode the viral nucleocapsid (N), envelope glycoproteins (G_N and G_C), and an RNA polymerase (Pol), respectively. More than 50 hantaviruses have been found worldwide [1]. Each hantavirus appears to have coevolved with a specific rodent or insectivore host as similar phylogenetic trees are produced from virus and host mitochondrial gene sequences [2]. Spillover to humans causes hemorrhagic fever with renal syndrome (HFRS) or hantavirus cardiopulmonary syndrome (HCPS), depending on the virus [3]–[5]. Although symptoms vary, a common feature of both HFRS and HCPS is increased permeability of the vasculature and mononuclear infiltration [4]. Pathogenesis of HRFS and HCPS in humans is hypothesized to be mediated by excessive proinflammatory and CD8+ T cell responses (​).

Table 1

Summary of Immune Responses in Humans during Hantavirus Infection.

Building global health research capacity to address research imperatives following the COVID-19 pandemic

Peter Kilmarx and Roger Glass discuss strengthening health research capabilities as a response to the COVID-19 pandemic.

Research and development of new tools and interventions are necessary to improve global health, as has been made apparent by the Coronavirus Disease 2019 (COVID-19) pandemic [1]. As of mid-July 2021, there have been nearly 190 million cases reported worldwide and more than 4 million deaths; and yet, less than a year after the outbreak was first reported, in an unprecedented global effort, researchers had developed home rapid self-tests [2], established treatment protocols proven effective to improve survival [3], and discovered highly effective vaccines that are already being produced and administered at a large scale [4].The COVID-19 pandemic also illustrates the importance of having research capacity in place as a critical element of pandemic preparedness. China, with its robust research capacity, was able to rapidly sequence the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus in January 2020 [5] and quickly share the results, thereby jumpstarting global development of diagnostic tests and vaccines. In contrast, when outbreaks have occurred in countries with less research capacity, the development of countermeasures—diagnostics, therapeutics, and vaccines—may be delayed. We examined the relationship between a country’s preexisting research capacity and the output of scientific publications in PubMed by the country’s scientists following an outbreak. In the first 2 years after the Ebola outbreak was recognized in Guinea, only 42 papers on Ebola were published with authors with a Guinean affiliation, and there were significant challenges in launching Ebola treatment and vaccine studies. From Brazil, with its strong research infrastructure, 312 publications about Zika were authored by scientists with a Brazilian affiliation in the 2 years after that outbreak was detected, and substantial progress was made in rapidly characterizing the newly recognized, diverse clinical manifestations. Finally, authors affiliated with a Chinese institution published 8,921 articles on COVID-19 since the current outbreak was recognized, with remarkable progress in developing medical countermeasures.Anticipating significant progress in controlling COVID-19 in 2021, what are the future priorities for global health research? A helpful guide is the 2019 report of the Global Burden of Diseases, Injuries, and Risk Factors Study [6]. This comprehensive synthesis showed that the largest absolute increases in number of disability-adjusted life years between 1990 and 2019 mostly included noncommunicable diseases, i.e., ischemic heart disease, diabetes, stroke, chronic kidney disease, and lung cancer. These illnesses have overlapping risk factors—hypertension, high fasting plasma glucose, high body mass index, tobacco use, and ambient air pollution—which are also highly prevalent and mostly increasing over time [7], further suggesting important areas for research. Notably, some of these diseases and risk factors are also predisposing factors for more severe COVID-19 and prolonged symptoms post-COVID-19.Many other critical COVID-19 research questions in the NIH-Wide Strategic Plan for COVID-19 Research [8] remain unanswered, and new urgent questions have arisen. These include the following: What can we learn from how genetic and other factors explain the high individual variation in the clinical course of COVID-19 to improve treatment interventions? How can diagnostic tests be optimized for home use and low-resource settings, and can testing platforms be created for rapid adaptation with new emerging pathogens? With the potential for waning immunity and immune escape variants, what strategies will be needed for COVID-19 vaccine booster doses? Lastly, how best can public health interventions and medical countermeasures be delivered to reduce poor outcomes, especially in racial/ethnic minority and other vulnerable populations?Several other important perspectives on threats to global health cut across multiple disease entities and provide useful frameworks and new imperatives for prioritizing global health research. The One Health concept encompasses interconnections between humans, animals, plants, and the environment and embraces a transdisciplinary approach to address major emerging threats including zoonotic diseases (e.g., COVID-19), vector-borne diseases, antimicrobial resistance, food safety, and environmental contamination [9]. Another framework is Planetary Health, which focuses on the already large and growing health impacts of our extensive disruptions of earth’s systems, especially climate change, but also declining biodiversity, increasing pollution, and shortages of fresh water, land, and ocean resources [10]. In addition, humanitarian crises such as armed conflicts, natural disasters, and disease outbreaks are impacting more people than ever before. New research approaches and partnerships are needed to address evidence gaps and to establish capacities for future challenges [11]. The impact of COVID-19 on routine health services is a striking current example. Lastly, implementation research on promoting the uptake of evidence-based interventions and policies into routine healthcare and public health settings is needed across each of these fields of health research to address persistent gaps between the promise of proven effective innovations and their successful implementation, especially in underserved and marginalized populations that have been more severely impacted by COVID-19 [12].We believe the greatest priority should be on building health research capacity in low- and middle-income countries (LMICs) where the health burdens and threats are greater and research capacity is often lower than in higher-income countries. Basic pillars of capacity are needed to establish a robust, responsive research environment. Foremost among these is human capacity. Over decades of experience, we have learned that developing research leaders in LMICs requires well-trained individuals with protected time to conduct research and with strong mentorship and networking with both international and local scientists. It is encouraging to see such investigators trained in other research topics such as HIV and tuberculosis now emerge as leaders in their country’s response to the COVID-19 pandemic in Asia, Africa, and the Americas [13]. Other critical capacities include laboratory testing, data management and statistical analysis, clinical trial and community research site development, behavioral and social science, community engagement, ethical review boards, and regulatory systems. A promising emerging approach is to use basic metrics of national and institutional health research capacity to help coordinate and increase efficiency of capacity building efforts, identify and support countries with lowest capacity levels, and facilitate increased research on national health priorities [14]. As we have seen with COVID-19, these capacities can also be rapidly brought to bear to address new health threats. Notably, of the 30 countries taking part in the SOLIDARITY trial of COVID-19 treatment, 16 are LMICs [15]. A critical limitation and emerging priority underscored by COVID-19 is in vaccine research, development, and manufacturing capacity, especially in Africa [16].COVID-19 has necessitated many other substantial changes in our usual practices of global health research, some of which are likely to persist. Use of digital platforms for telecommunications has exploded. In many settings, telework and distance learning are proving to be very effective and sometimes preferable to the expense and risk of face-to-face meetings. We have seen greater participation in many webinars and network meetings, especially from early-career and LMIC colleagues who did not have the time or the budget for in-person meetings [17]. Importantly, the environmental costs of these virtual meetings are also much lower. Along with increases in telemedicine, there have also been advances in teleresearch whereby participants can be enrolled or followed via their mobile phones, potentially decreasing the costs and barriers to participation and improving study retention. The speed of research, formation of collaborations, and communication of results have all increased remarkably with digital collaboration platforms and rapid publication, including publication of preprints, which are now available on PubMed [18]. International collaboration and coordination in research and regulatory processes have also been critical to the rapid development of medical countermeasures through platforms such as the Access to COVID-19 Tools (ACT) Accelerator of the World Health Organization [19] and the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) public–private partnership led by the National Institutes of Health [20].Unfortunately, there has also been an “infodemic” of misinformation (i.e., any false information) and disinformation (deliberately false or misleading information) around the source and impact of COVID-19 and the science of its prevention and treatment [21]. This is not a new phenomenon, but with the growth of digital platforms with domestic and international rivalries, a major threat has emerged requiring research to better understand and counter that threat.Finally, COVID-19 is likely to recalibrate perspectives of levels of expertise in north–south relationships among higher- and lower-income countries. At the time of this writing, the public health, healthcare system, and policy approaches in the COVID-19 response of many high-income countries in the north have greatly underperformed in comparison to some lower-income countries in the global south, especially in regard to protecting vulnerable and marginalized populations. This has increased momentum to democratize global health, with the recognition that a new sense of humility and equity will be critical to understand all of the lessons to be learned and improve global health following COVID-19. We applaud the growing role of LMIC scientists in setting the global health research agenda [22].In conclusion, while the COVID-19 pandemic has already taken a devastating global toll on global health and well-being, it has also provided a strong example of the importance of health research capacity as an essential element of pandemic preparedness. The world faces a wide range of health challenges, from chronic diseases and risk factors to emerging global threats. Building research capacity, especially in countries with lower levels, while learning the lessons of COVID-19, must become a higher priority to achieve our current shared global health goals while increasing resilience to address future health threats.     

Introducing the Outbreak Threshold in Epidemiology

When a pathogen is rare in a host population, there is a chance that it will die out because of stochastic effects instead of causing a major epidemic. Yet no criteria exist to determine when the pathogen increases to a risky level, from which it has a large chance of dying out, to when a major outbreak is almost certain. We introduce such an outbreak threshold (T₀), and find that for large and homogeneous host populations, in which the pathogen has a reproductive ratio R₀, on the order of 1/Log(R₀) infected individuals are needed to prevent stochastic fade-out during the early stages of an epidemic. We also show how this threshold scales with higher heterogeneity and R₀ in the host population. These results have implications for controlling emerging and re-emerging pathogens.With the constant risk of pathogens emerging [1], such as Severe Acute Respiratory Syndrome (SARS) or avian influenza virus in humans, foot-and-mouth disease virus in cattle in the United Kingdom [2], or various plant pathogens [3], it is imperative to understand how novel strains gain their initial foothold at the onset of an epidemic. Despite this importance, it has seldom been addressed how many infected individuals are needed to declare that an outbreak is occurring: that is, when the pathogen can go extinct due to stochastic effects, to when it infects a high enough number of hosts such that the outbreak size increases in a deterministic manner (Figure 1A). Generally, the presence of a single infected individual is not sufficient to be classified as an outbreak, so how many infected individuals need to be present to cause this deterministic increase? Understanding at what point this change arises is key in preventing and controlling nascent outbreaks as they are detected, as well as determining the best course of action for prevention or treatment.Open in a separate windowFigure 1The outbreak threshold in homogeneous and heterogeneous populations.(A) A schematic of pathogen emergence. This graph shows the early stages of several strains of an epidemic, where R₀ = 1.25. The black line denotes the outbreak threshold (T ₀ = 1/Log(R₀) = 4.48). Blue thin lines show cases in which the pathogen goes extinct and does not exceed the threshold; the red thick line shows an epidemic that exceeds the threshold and persists for a long period of time. Simulations were based on the Gillespie algorithm [22]. (B) Outbreak threshold in a homogeneous (black thick line) or in a heterogeneous population, for increasing R₀. The threshold was calculated following the method described by Lloyd-Smith et al. [11] and is shown for different values of k, the dispersion parameter of the offspring distribution, as obtained from data on previous epidemics [11]. If the threshold lies below one, this means that around only one infected individual is needed to give a high outbreak probability.The classic prediction for pathogen outbreak is that the pathogen''s reproductive ratio (R₀), the number of secondary infections caused by an infected host in a susceptible population, has to exceed one [4], [5]. This criterion only strictly holds in deterministic (infinite population) models; in finite populations, there is still a chance that the infection will go extinct by chance rather than sustain itself [4]–[6]. Existing studies usually consider random drift affecting outbreaks in the context of estimating how large a host population needs to be to sustain an epidemic (the “Critical Community Size” [4], [7], [8]), calculating the outbreak probability in general [9]–[12], or ascertaining whether a sustained increase in cases over an area has occurred [13]. Here we discuss the fundamental question of how many infected individuals are needed to almost guarantee that a pathogen will cause an outbreak, as opposed to the population size needed to maintain an epidemic once it has appeared (Critical Community Size; see also Box 1). We find that only a small number of infected individuals are often needed to ensure that an epidemic will spread.

Box 1. Glossary of Key Terms

• The Basic Reproductive Ratio (R₀) is the number of secondary infections caused by a single infected individual, in a susceptible population. It is classically used to measure the rate of pathogen spread. In infinite-population models, a pathogen can emerge if R₀>1. In a finite population, the pathogen can emerge from a single infection with probability 1-1/R₀ if R₀>1, otherwise extinction is certain.
• The Critical Community Size (CCS) is defined as the total population size (of susceptible and infected individuals, or others) needed to sustain an outbreak once it has appeared. This idea was classically applied to determining what towns were most likely to maintain measles epidemics [7], so that there would always be some infected individuals present, unless intervention measures were taken.
• The Outbreak Threshold (T₀) has a similar definition to the CSS, but is instead for use at the onset of an outbreak, rather than once it has appeared. It measures how many infected individuals (not the total population size) are needed to ensure that an outbreak is very unlikely to go extinct by drift. Note that the outbreak can still go extinct in the long term, even if T₀ is exceeded, if there are not enough susceptible individuals present to carry the infection afterwards.

We introduce the concept of the outbreak threshold (denoted T₀), which we define as the number of infected individuals needed for the disease to spread in an approximately deterministic manner. T₀ can be given by simple equations. Indeed, if the host population is homogeneous (that is, where there is no individual variability in reproductive rates) and large enough so that depletion of the pool of susceptible hosts is negligible, then the probability of pathogen extinction if I infected hosts are present is (1/R₀)^I ([6], details in Material S.1 in Text S1). By solving this equation in the limit of extinction probability going to zero, we find that on the order of 1/Log(R₀) infected hosts are needed for an outbreak to be likely (black thick curve in Figure 1B), a result that reflects similar theory from population genetics [14]–[16]. Note that this result only holds in a finite population, as an outbreak in a fully susceptible infinite population is certain if R₀>1 ([4], see also Material S.1 in Text S1).This basic result can be modified to consider more realistic or precise cases, and T₀ can be scaled up if an exact outbreak risk is desired. For example, for the pathogen extinction probability to be less than 1%, there needs to be at least 5/Log(R₀) infected individuals. More generally, the pathogen extinction probability is lower than a given threshold c if there are at least −Log(c)/Log(R₀) infected individuals. Furthermore, if only a proportion p<1 of all infected individuals are detected, then the outbreak threshold order is p/Log(R₀). Also, if there exists a time-lag τ between an infection occurring and its report, then the order of T₀ is e^−τ(β-δ)/Log(R₀), where β is the infection transmission rate and 1/δ the mean duration of the infectious period (Material S.1 in Text S1). Finally, we can estimate how long it would take, on average, for the threshold to be reached and find that, if the depletion in susceptible hosts is negligible, this duration is on the order of 1/(β-δ) (Material S.1 in Text S1).So far we have only considered homogenous outbreaks, where on average each individual has the same pathogen transmission rate. In reality, there will be a large variance among individual transmission rates, especially if “super-spreaders” are present [17]. This population heterogeneity can either be deterministic, due to differences in immune history among hosts or differences in host behavior, or stochastic, due to sudden environmental or social changes. Spatial structure can also act as a form of heterogeneity, if each region or infected individual is subject to different transmission rates, or degree of contact with other individuals [18]. In such heterogeneous host populations, the number of secondary cases an infected individual engenders is jointly captured by R₀ and a dispersion parameter k (see Box 2). This dispersion parameter controls the degree of variation in individual transmission rates, while fixing the average R₀. The consequence of this model is that the majority of infected hosts tend to cause few secondary infections, while the minority behave as super-spreaders, causing many secondary infections. Host population heterogeneity (obtained with lower values of k) increases the probability that an outbreak will go extinct, as the pathogen can only really spread via one of the dwindling super-spreading individuals. In this heterogeneous case, we can find accurate values of T₀ numerically. As shown in Figure 1B, if R₀ is close to 1, host heterogeneity (k) does not really matter (T₀ tends to be high). However, if the pathogen has a high R₀ and thus spreads well, then host heterogeneity strongly affects T₀. Additionally, we find that the heterogeneous threshold simply scales as a function of k and R₀² (see Box 2). As an example, if k = 0.16, as estimated for SARS infections [11], the number of infected individuals needed to guarantee an outbreak increases 4-fold compared to a homogeneous population (Material S.3 in Text S1).

Box 2. Heterogeneous Outbreak Threshold

In a heterogeneous host population (see the main text for the bases of this heterogeneity), it has been shown that the number of secondary infections generated per infected individual can be well described by a negative binomial distribution with mean R₀ and dispersion parameter k [11]. The dispersion parameter determines the level of variation in the number of secondary infections: if k = 1, we have a homogeneous outbreak, but heterogeneity increases as k drops below 1; that is, it enlarges the proportion of infected individuals that are either “super-spreaders” or “dead-ends” (those that do not transmit the pathogen). Lloyd-Smith et al. [11] showed how to estimate R₀ and k from previous epidemics through applying a maximum-likelihood model to individual transmission data.Although in this case it is not possible to find a strict analytical form for the outbreak threshold, progress can be made if we measure the ratio of the heterogeneous and homogeneous thresholds. This function yields values that are independent of a strict cutoff probability (Material S.3 in Text S1). By investigating this ratio, we first found that for a fixed R₀, a function of order 1/k fitted the numerical solutions very well. By measuring these curves for different R₀ values, we further found that a function of order 1/R₀ ² provided a good fit to the coefficients. By fitting a function of order 1/kR₀ ² to the numerical data using least-squares regression in Mathematica 8.0 [19], we obtained the following adjusted form for the outbreak threshold T₀ in a heterogeneous population:(1)As in the homogeneous case, T₀ only provides us with an order of magnitude and it can be multiplied by −Log(c) to find the number of infected hosts required for there to be a probability of outbreak equal to 1-c. A sensitivity analysis shows that Equation 1 tends to be more strongly affected by changes in R₀ than in k (Material S.3 in Text S1).The outbreak threshold T₀ of an epidemic, which we define as the number of infected hosts above which there is very likely to be a major outbreak, can be estimated using simple formulae. Currently, to declare that an outbreak has occurred, studies choose an arbitrary low or high threshold depending, for instance, on whether they are monitoring disease outbreaks or modeling probabilities of emergence. We show that the outbreak threshold can be defined without resorting to an arbitrary cutoff. Of course, the generality of this definition has a cost, which is that the corresponding value of T₀ is only an order of magnitude. Modifications are needed to set a specific cutoff value or to capture host heterogeneity in transmission or incomplete sampling.These results are valid if there are enough susceptible individuals present to maintain an epidemic in the initial stages, as assumed in most studies on emergence [6], [11]–[13], otherwise the pathogen may die out before the outbreak threshold is reached (Box 3 and Material S.2 in Text S1). Yet the key message generally holds that while the number of infections lies below the threshold, there is a strong chance that the pathogen will vanish without causing a major outbreak. From a biological viewpoint, unless R₀ is close to one, these thresholds tend to be small (on the order of 5 to 20 individuals). This contrasts with estimates of the Critical Community Size, which tend to lie in the hundreds of thousands of susceptible individuals [3], [7], [8]. Therefore, while only a small infected population is needed to trigger a full-scale epidemic, a much larger pool of individuals are required to maintain an epidemic, once it appears, and prevent it from fading out. This makes sense, since there tends to be more susceptible hosts early on in the outbreak than late on.

Box 3. Effect of Limiting Host Population Size

The basic result for the homogeneous population, T₀∼1/Log(R₀), assumes that during the time to pathogen outbreak, there are always enough susceptible individuals available to transmit to, so R₀ remains approximately constant during emergence. This assumption can be violated if R₀ is close to 1, or if the population size is small. More precisely, if the maximum outbreak size in a Susceptible-Infected-Recovered (SIR) epidemic, which is given byis less than 1/Log(R₀), then the threshold cannot be reached. Since this maximum is dependent on the population size, outbreaks in smaller populations are less likely to reach the outbreak threshold. For example, if N = 10,000 then R₀ needs to exceed 1.06 for 1/Log(R₀) to be reached; this increases to 1.34 if N decreases to 100. Further details are in Material S.2 in Text S1.Estimates of R₀ and k from previous outbreaks can be used to infer the approximate size of this threshold, to determine whether a handful or hundreds of infected individuals are needed for an outbreak to establish itself. Box 4 outlines two case studies (smallpox in England and SARS in Singapore), estimates of T₀ for these, and how knowledge of the threshold could have aided their control. These examples highlight how the simplicity and rigorousness of the definition of T₀ opens a wide range of applications, as it can be readily applied to specific situations in order to determine the most adequate policies to prevent pathogen outbreaks.

Box 4. Two Case Studies: Smallpox in England and SARS in Singapore

A smallpox outbreak (Variola minor) was initiated in Birmingham, United Kingdom in 1966 due to laboratory release. We calculate a threshold such that the chance of extinction is less than 0.1%, which means that T₀ is equal to 7 times Equation 1. With an estimated R₀ of 1.6 and dispersion parameter k = 0.65 [11], T₀ is approximately equal to 9 infections. The transmission chain for this outbreak is now well-known [20]. Due to prior eradication of smallpox in the United Kingdom, the pathogen was not recognised until around the 45^th case was detected, by which point a full-scale epidemic was underway. A second laboratory outbreak arose in 1978, but the initial case (as well as a single secondary case) was quickly isolated, preventing a larger spread of the pathogen. Given the fairly low T₀ for the previous epidemic, early containment was probably essential in preventing a larger outbreak.The SARS outbreak in Singapore in 2003 is an example of an outbreak with known super-spreaders [21], with an estimated initial R₀ of 1.63 and a low k of 0.16 [11]. T₀ is estimated to be around 27 infections. The first cases were observed in late February, with patients being admitted for pneumonia. Strict control measures were invoked from March 22^nd onwards, including home quarantining of those exposed to SARS patients and closing down of a market where a SARS outbreak was observed. By this date, 57 cases were detected, although it is unclear how many of those cases were still ongoing on the date. This point is important, as it is the infected population size that determines T₀.Overall, very early measures were necessary to successfully prevent a smallpox outbreak due to its rapid spread. In theory, it should have been “easier” to contain the SARS outbreak, as its threshold is three times greater than that for smallpox due to higher host heterogeneity (k). However, the first reported infected individual was a super-spreader, who infected at least 21 others. This reflects that in heterogeneous outbreaks, although the emergence probability is lower, the disease spread is faster (compared to homogeneous infections) once it does appear [11]. Quick containment of the outbreak was difficult to achieve since SARS was not immediately recognised, as well as the fact that the incubation period is around 5 days, by which point it had easily caused more secondary cases. However, in subsequent outbreaks super-spreaders might not be infected early on, allowing more time to contain the spread.For newly-arising outbreaks, T₀ can be applied in several ways. If the epidemic initially spreads slowly, then R₀ and T₀ can be measured directly. Alternatively, estimates of T₀ can be calculated from previous outbreaks, as outlined above. In both cases, knowing what infected population size is needed to guarantee emergence can help to assess how critical a situation is. More generally, due to the difficulty in detecting real-world outbreaks that go extinct very quickly, experimental methods might be useful in determining to what extent different levels of T₀ capture the likelihood of full epidemic emergence.     

Scabies in remote Aboriginal and Torres Strait Islander populations in Australia: A narrative review

Scabies has recently gained international attention, with the World Health Organization (WHO) recognizing it as a neglected tropical disease. The International Alliance for the Control of Scabies recently formed as a partnership of more than 15 different countries, with an aim to lead a consistent and collaborative approach to preventing and controlling scabies globally. Scabies is most prevalent in low-resource and low socioeconomic areas that experience overcrowding and has a particularly high prevalence in children, with an estimated 5% to 10% in endemic countries. Scabies is widespread in remote Aboriginal and Torres Strait Islander communities in Australia with the prevalence of scabies in Aboriginal and Torres Strait Islander children in remote communities estimated to be as high as 33%, making it the region with the third highest prevalence in the world. This population group also have very high rates of secondary complications of scabies such as impetigo, poststreptococcal glomerulonephritis (PSGN), and rheumatic heart disease (RHD). This article is a narrative review of scabies in remote Aboriginal and Torres Strait Islander populations in Australia, including clinical manifestations of disease and current treatment options and guidelines. We discuss traditional approaches to prevention and control as well as suggestions for future interventions including revising Australian treatment guidelines to widen the use of oral ivermectin in high-risk groups or as a first-line treatment.

Scabies has recently gained international attention, with the World Health Organization (WHO) recognizing it as a neglected tropical disease [1]. The International Alliance for the Control of Scabies recently formed as a partnership of more than 15 different countries, with an aim to lead a consistent and collaborative approach to preventing and controlling scabies globally [2]. In Australia, 10 million dollars was awarded to the Murdoch Children’s Research Institute to implement the World Scabies Elimination Program—an initiative aimed at collecting data from many affected countries and scaling up mass drug administration (MDA) [3].Scabies is most prevalent in low-resource and low socioeconomic areas that experience overcrowding and has a particularly high prevalence in children, with an estimated 5% to 10% in endemic countries [4,5]. The 2015 Global Burden of Disease Study ranked scabies with the 101st highest disability-adjusted life years (DALYs) estimate out of 246 conditions [6]. This is, however, likely underestimated as secondary complications, such as impetigo and kidney damage, were not included in this study [6,7]. A study from Fiji showed that 94% of impetigo was attributable to scabies [8], and it is estimated that approximately half of the instances of acute poststreptococcal glomerulonephritis (PSGN) in tropical regions can be attributed to skin infections [9].     

Residues Important for Nitrate/Proton Coupling in Plant and Mammalian CLC Transporters

Members of the CLC gene family either function as chloride channels or as anion/proton exchangers. The plant AtClC-a uses the pH gradient across the vacuolar membrane to accumulate the nutrient in this organelle. When AtClC-a was expressed in Xenopus oocytes, it mediated exchange and less efficiently mediated Cl^–/H⁺ exchange. Mutating the “gating glutamate” Glu-203 to alanine resulted in an uncoupled anion conductance that was larger for Cl^– than . Replacing the “proton glutamate” Glu-270 by alanine abolished currents. These could be restored by the uncoupling E203A mutation. Whereas mammalian endosomal ClC-4 and ClC-5 mediate stoichiometrically coupled 2Cl^–/H⁺ exchange, their transport is largely uncoupled from protons. By contrast, the AtClC-a-mediated accumulation in plant vacuoles requires tight coupling. Comparison of AtClC-a and ClC-5 sequences identified a proline in AtClC-a that is replaced by serine in all mammalian CLC isoforms. When this proline was mutated to serine (P160S), Cl^–/H⁺ exchange of AtClC-a proceeded as efficiently as exchange, suggesting a role of this residue in exchange. Indeed, when the corresponding serine of ClC-5 was replaced by proline, this Cl^–/H⁺ exchanger gained efficient coupling. When inserted into the model Torpedo chloride channel ClC-0, the equivalent mutation increased nitrate relative to chloride conductance. Hence, proline in the CLC pore signature sequence is important for exchange and conductance both in plants and mammals. Gating and proton glutamates play similar roles in bacterial, plant, and mammalian CLC anion/proton exchangers.CLC proteins are found in all phyla from bacteria to humans and either mediate electrogenic anion/proton exchange or function as chloride channels (1). In mammals, the roles of plasma membrane CLC Cl^– channels include transepithelial transport (2–5) and control of muscle excitability (6), whereas vesicular CLC exchangers may facilitate endocytosis (7) and lysosomal function (8–10) by electrically shunting vesicular proton pump currents (11). In the plant Arabidopsis thaliana, there are seven CLC isoforms (AtClC-a–AtClC-g)² (12–15), which may mostly reside in intracellular membranes. AtClC-a uses the pH gradient across the vacuolar membrane to transport the nutrient nitrate into that organelle (16). This secondary active transport requires a tightly coupled exchange. Astonishingly, however, mammalian ClC-4 and -5 and bacterial EcClC-1 (one of the two CLC isoforms in Escherichia coli) display tightly coupled Cl^–/H⁺ exchange, but anion flux is largely uncoupled from H⁺ when is transported (17–21). The lack of appropriate expression systems for plant CLC transporters (12) has so far impeded structure-function analysis that may shed light on the ability of AtClC-a to perform efficient exchange. This dearth of data contrasts with the extensive mutagenesis work performed with CLC proteins from animals and bacteria.The crystal structure of bacterial CLC homologues (22, 23) and the investigation of mutants (17, 19–21, 24–29) have yielded important insights into their structure and function. CLC proteins form dimers with two largely independent permeation pathways (22, 25, 30, 31). Each of the monomers displays two anion binding sites (22). A third binding site is observed when a certain key glutamate residue, which is located halfway in the permeation pathway of almost all CLC proteins, is mutated to alanine (23). Mutating this gating glutamate in CLC Cl^– channels strongly affects or even completely suppresses single pore gating (23), whereas CLC exchangers are transformed by such mutations into pure anion conductances that are not coupled to proton transport (17, 19, 20). Another key glutamate, located at the cytoplasmic surface of the CLC monomer, seems to be a hallmark of CLC anion/proton exchangers. Mutating this proton glutamate to nontitratable amino acids uncouples anion transport from protons in the bacterial EcClC-1 protein (27) but seems to abolish transport altogether in mammalian ClC-4 and -5 (21). In those latter proteins, anion transport could be restored by additionally introducing an uncoupling mutation at the gating glutamate (21).The functional complementation by AtClC-c and -d (12, 32) of growth phenotypes of a yeast strain deleted for the single yeast CLC Gef1 (33) suggested that these plant CLC proteins function in anion transport but could not reveal details of their biophysical properties. We report here the first functional expression of a plant CLC in animal cells. Expression of wild-type (WT) and mutant AtClC-a in Xenopus oocytes indicate a general role of gating and proton glutamate residues in anion/proton coupling across different isoforms and species. We identified a proline in the CLC signature sequence of AtClC-a that plays a crucial role in exchange. Mutating it to serine, the residue present in mammalian CLC proteins at this position, rendered AtClC-a Cl^–/H⁺ exchange as efficient as exchange. Conversely, changing the corresponding serine of ClC-5 to proline converted it into an efficient exchanger. When proline replaced the critical serine in Torpedo ClC-0, the relative conductance of this model Cl^– channel was drastically increased, and “fast” protopore gating was slowed.     

The relation of family violence, employment status, welfare benefits, and alcohol drinking in the United States

Objective To examine the contribution of employment status, welfare benefits, alcohol use, and other individual and contextual factors to physical aggression during marital conflict. Methods Logistic regression models were used to analyze panel data collected in the National Survey of Families and Households in 1987 and 1992. A total of 4,780 married or cohabiting persons reinterviewed in 1992 were included in the analysis. Domestic violence was defined as reporting that both partners were physically violent during arguments. Results Unemployed respondents are not at greater risk of family violence than employed respondents, after alcohol misuse, income, education, age, and other factors are controlled for; however, employed persons receiving welfare benefits are at significantly higher risk. Alcohol misuse, which remains a predictor of violence even after other factors are controlled for, increases the risk of family violence, and satisfaction with social support from family and friends is associated with its decrease. Conclusions Alcohol misuse has an important effect on domestic violence, and the potential impact of welfare reform on domestic violence needs to be monitored.Family violence has been recognized as a public health problem for almost a decade,¹ and the health care cost associated with the treatment of family violence injuries in the United States has been estimated as high as $857 million annually.² In analyzing 1985 National Violence Survey data, Straus and Gelles found an annual incidence of marital aggression of about 16%.³ In 1992, 12% of all homicides were the result of intrafamilial violence.⁴ Estimates are that as many as 2 to 4 million women a year are physically battered by their intimate partners.⁵ Women are as likely as men to resort to physical aggression during marital conflicts, but women are more likely to report injury from such interchanges.⁶Family violence has been associated with gender and power issues^7,8,9; structural and sociodemographic characteristics such as age, socioeconomic status, unemployment, cohabiting status, and partnership stability^10,11,12,13; alcohol and drug misuse^14,15; and depression.^16,17 The research on family violence has produced results that are difficult to integrate conceptually or empirically. Most of this research has been on small selected samples and cross-sections.The role of alcohol in violence is especially controversial.^14,18,19 Studies have found that alcohol use may aggravate marital difficulties, leading to separation or divorce,¹⁷ and alcohol problems may have an indirect effect on earnings and marriage.^20,21 One longitudinal study, however, found that alcohol consumption was significantly related to physical aggression 6 months immediately before and after marriage, but the effects washed out at 18 months.²² Others have suggested that structural factors such as unemployment may disrupt community and social relationships, leading to greater risk behavior such as alcohol consumption.¹³ Unemployment, however, has been inconsistently related to both alcohol intake^13,23 and violent incidents.²⁴ Job loss has been found to be related to an increase of negative behaviors between partners,²⁴ but again, the relation between job loss and violence is not clear-cut. Although small increases in layoffs are associated with more violent incidents, large increases are associated with a reduced incidence.²⁵Employment in itself does not necessarily protect couples from marital violence. Stressful work experiences have also been associated with wife abuse.²⁶ In addition, it has been suggested that an increase of female employment and transitions toward different forms of relationships may generate tensions that increase the likelihood of marital violence.²⁷ This is particularly relevant given our fast-changing economy and increasing employment demands on young parents,^28,29 including those receiving welfare benefits.There is evidence that welfare reform accounted for 44% of the employment rate gain from 1992 to 1996^30,31 and that the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law 104-193) has forced more women with young children to work. In the current policy debate, not only is there little concern for the effect of welfare reform on women''s health,³² but little thought has been given to a potential for increased domestic violence.Social scientists increasingly note the importance of taking context into account when explaining outcomes and the necessity of looking at the way in which family, work, and community factors interrelate to explain attitudes and behaviors.^33,34,35,36 Research on violence should also consider the effects of social and economic environmental factors.^37,38The goal of this study was to contribute to our understanding of the complex and important issue of family violence. Using panel data from the 1987 and 1992 National Survey of Families and Households (NSFH), we attempted to disentangle the effects of employment, partnership instability, and alcohol use on the risk of domestic violence.The figure summarizes our explanatory model. We took advantage of longitudinal data, and controlling for individual and household characteristics and prior problems with alcohol misuse, violent arguments, and joblessness (1987 and 1991 variables), we ascertained the influence of current alcohol misuse and employment status on current violence (1992 variable). Our explanatory model draws from a sociostructural approach, in that violent arguments are seen as arising from changing and increasing demands placed on the family,^26,38 and from a social learning approach that considers the influence of variables such as occupational status on the onset of violence.²⁶ We broadened the employment status variable to include working and receiving welfare.     

Sleep loss leads to the withdrawal of human helping across individuals,groups, and large-scale societies

Humans help each other. This fundamental feature of homo sapiens has been one of the most powerful forces sculpting the advent of modern civilizations. But what determines whether humans choose to help one another? Across 3 replicating studies, here, we demonstrate that sleep loss represents one previously unrecognized factor dictating whether humans choose to help each other, observed at 3 different scales (within individuals, across individuals, and across societies). First, at an individual level, 1 night of sleep loss triggers the withdrawal of help from one individual to another. Moreover, fMRI findings revealed that the withdrawal of human helping is associated with deactivation of key nodes within the social cognition brain network that facilitates prosociality. Second, at a group level, ecological night-to-night reductions in sleep across several nights predict corresponding next-day reductions in the choice to help others during day-to-day interactions. Third, at a large-scale national level, we demonstrate that 1 h of lost sleep opportunity, inflicted by the transition to Daylight Saving Time, reduces real-world altruistic helping through the act of donation giving, established through the analysis of over 3 million charitable donations. Therefore, inadequate sleep represents a significant influential force determining whether humans choose to help one another, observable across micro- and macroscopic levels of civilized interaction. The implications of this effect may be non-trivial when considering the essentiality of human helping in the maintenance of cooperative, civil society, combined with the reported decline in sufficient sleep in many first-world nations.

Helping behavior between humans has been one of the most influential forces sculpting modern civilizations, but what factors influence this propensity to help? This study demonstrates that a lack of sleep dictates whether humans choose to help each other at three different scales: within individuals, across individuals, and across societies.

“Service to others is the rent you pay for your room here on earth.”― Muhammad Ali

Humans help each other. Helping is a prominent feature of homo sapiens [1], and represents a fundamental force sculpting the advent and preservation of modern civilizations [2,3].The ubiquity of helping is evident across the full spectrum of societal strata. From global government-to-government aid packages (e.g., the international aid following the 2004 Indian Ocean tsunami [4]), to country-wide pledge drives (e.g., the 2010 Haiti disaster) [5], and to individuals altruistically gifting money or donating their own blood to strangers, the expression of helping is abundant and pervasive [6]. So much so that this fundamental act has scaled into a lucent and sizable “helping economy” [7], with charitable giving in the United States amounting to $450 billion in 2019; a value representing 5.5% of the gross domestic product. In the United Kingdom, 10 billion pounds were donated to charity in 2017 and 2018. Indeed, more than 50% of individuals across the US, Europe, and Asia will have reported donating to charity or helping a stranger within the past month (The World Giving index).Human helping is therefore globally abundant, common across diverse societies, sizable in scope, substantive in financial magnitude, consequential in ramification, and frequent in occurrence.The motivated drive for humans to help each other has been linked to a range of underlying factors, from evolutionary forces (e.g., kin selection and reciprocal altruism that bias helping toward close others [2]), cultural norms and expectations (e.g., individualistic versus collectivistic cultures [8,9]), to socioeconomic factors (e.g., helping is less common in larger cities relative to rural areas [10,11]), as well as personality traits (e.g., individual empathy) [12,13].Ultimately, however, the decisional act to help others involves the human brain. Prosocial helping of varied kinds consistently engages a set of brain regions known as the social cognition network. Comprised of the medial prefrontal cortex (mPFC), mid and superior temporal sulcus, temporal-parietal junction (TPJ), and the precuneus [14,15], this network is activated when considering the mental states, needs, and perspectives of others [16–19], and the active choice to help them [20–23]. In contrast, lesions within key regions of this network result in “acquired sociopathy” [24], associated with a loss of both empathy and the withdrawal of compassionate helping [25–27].Yet the possibility that sleep loss represents another significant factor determining whether or not humans help each other, linked to underlying impairments within the social cognition brain network, remains unknown. Several lines of evidence motivate this prediction. First, insufficient sleep impairs emotional processing, including deficits in emotion recognition and expression, while conversely increasing basic emotional reactivity, further linked to antisocial behavior [28,29] (such as increased interpersonal conflict [30] and reduced trust in others [31,32]). Second, sleep loss reliably decreases activity in, and disrupts functional connectivity between, numerous regions within the social cognition brain network [33], including the mPFC [34], TPJ, and precuneus [35].Building on this overarching hypothesis, here, we test the prediction that a lack of sleep impairs human helping at a neural, individual, group, and global societal level. More specifically, we tested whether: (i) within individuals, a night of experimental sleep loss decreases the fundamental desire to help others, the underlying neural mechanism of which is linked to impaired activity within the social cognition brain network when considering other individuals (Study 1), (ii) in a micro-longitudinal study, night-to-night fluctuations in sleep result in a corresponding next-day deficit in the desire to act altruistically and helping others (Study 2), and (iii) at a large-scale national level, the loss of 1 h of sleep opportunity, using the manipulation of daylight saving time (DST), impairs the real-world behavioral act of altruistic human helping at a large-scale, societal level (Study 3).     

Overview of Nonhuman Primate Models of SARS-CoV-2

COVID-19, the disease caused by the SARS-CoV-2 betacoronavirus, was declared a pandemic by the World Health Organization on March 11, 2020. Since then, SARS-CoV-2 has triggered a devastating global health and economic emergency. In response, a broad range of preclinical animal models have been used to identify effective therapies and vaccines. Current animal models do not express the full spectrum of human COVID-19 disease and pathology, with most exhibiting mild to moderate disease without mortality. NHPs are physiologically, genetically, and immunologically more closely related to humans than other animal species; thus, they provide a relevant model for SARS-CoV-2 investigations. This overview summarizes NHP models of SARS-CoV-2 and their role in vaccine and therapeutic development.

Coronaviruses are enveloped, single-stranded, positive-sense, RNA viruses in the subfamily Orthocoronavirinae, family Coronaviridae, order Nidovirales. There are 4 coronavirus genera, that is, Alphacoronavirus and Betacoronavirus, which infect mammals; and Gammacoronavirus and Deltacoronavirus, which primarily infect birds, with some able to infect mammals.¹³³ From these natural reservoirs, coronaviruses may infect other animals and humans. Human transmission typically requires an intermediate host.Prior to the 2002 SARS-CoV epidemic, only 2 human coronaviruses (HCoVs) had been identified - an alphacoronavirus (HCoV-229E) transmitted from bats to humans by alpacas, and a betacoronavirus (HCoV-OC43) transmitted from rodents to humans by cattle.^16,18 In 2004, HCoV-NL63 (alphacoronavirus, bat reservoir) and in 2005, HCoV-HKU1 (betacoronavirus, rodent reservoir) were identified.^39,132 Together, these 4 HCoVs cause an estimated 15% to 30% of common cold cases in humans, but can cause severe infections in infants, juvenile children, and the elderly.^23,64 However, in 2002, a new betacoronavirus caused an epidemic that originated in China, resulting in 8,000 confirmed cases with a mortality rate of 9.6%. The virus was named SARS-CoV and was transmitted from bats to humans by a palm civet intermediate host.^59,63,83 Ten years later in June 2012, MERS-CoV, a novel betacoronavirus transmitted from bats to humans by dromedary camels, emerged in Saudi Arabia.^17,25 MERS-CoV was also responsible for a 2015 outbreak in South Korea. Although human-to-human transmission of MERS-CoV was limited, the virus resulted in more than 2,000 confirmed cases and a mortality rate of approximately 35%.⁹ Elderly people and those with comorbidities were more likely to develop severe disease.⁴³Seven y later, in December 2019, another novel betacoronavirus named SARS-CoV-2, emerged in Wuhan City, Hubei Province China.^19,26 The animal reservoir responsible for transmission to humans has not been definitively identified but has been reported to be bats.^4,143 In February 2020, the World Health Organization named the disease associated with SARS-CoV-2, Corona virus disease 19 (COVID-19) and declared it a pandemic on March 11, 2020.^22,62,95 COVID-19 causes fever and pneumonia that can progress to acute respiratory distress syndrome (ARDS), multiple organ dysfunction and failure, coagulopathy, and death.³¹ Common gross findings in human autopsy specimens include lung consolidation, pulmonary edema, increased lung weight, pleurisy, white mucous and pink froth in airways, and hemorrhage. Histopathologic changes of human COVID-19 follow a timeline relative to the onset of symptoms.⁸⁶ During early infection, microvascular damage, thrombi, exudate formation, and intra-alveolar fibrin deposits occur. Epithelial changes can be present at all stages of disease, specifically diffuse alveolar damage (DAD), which includes hyaline membrane formation, epithelial denudation and pneumocyte hyperplasia. Finally, interstitial fibrosis develops about 3 wk after symptom onset.¹¹⁰ The clinical presentation of those infected with SARS-CoV-2 ranges from mild to severe to critical in 81%, 14%, and 5% of cases, respectively.^135,145 Similar to SARS-CoV and MERS-CoV, severe disease from SARS-CoV-2 is more likely in elderly individuals or in those with comorbidities.^12,72,127 In a New York City hospital study, deaths among hospital patients at the study endpoint were 3.3% or lower in patients in their 40s or younger, 4.8% among those in their 50s, 6.4% in their 60s, 12.6% in their 70s, and 25.9% in their 80s or above. Age related death rates reported by China, Italy and France are similar to the United States. Reported rates of asymptomatic infection range from 4% to 32%; however,¹²⁷ a systematic review concluded that true asymptomatic infection could be uncommon.^8,82,111,127The contagiousness of an infectious disease is referred to as the R₀, or reproduction number, and indicates the average number of people who will contract a contagious disease from someone infected with that disease. SARS-CoV (R₀ of 1.5 to 1.9)^12,72,127 and MERS-CoV (R₀ of less than 1) have R₀ values lower than SARS-CoV-2 (initial R₀ was calculated to be 2.0 to 2.5, now revised upward to 5.7) and a lower fatality rate (2.3%).^84,97 As of December 26, 2020, 78,604,532 confirmed SARS-CoV-2 cases and 1,744,235 COVID-19 related deaths have been reported worldwide.¹²⁹ The global impact of COVID-19 has been catastrophic, with adverse effects on physical and mental health, an overwhelming need for health care resources, and increased poverty and economic insecurity.⁴⁷ Effective vaccines and therapeutics are key to controlling the SARS-CoV-2 pandemic. The success of these efforts depends in part on animal models that replicate human COVID-19 disease.^52,81,105The ideal animal model for SARS-CoV-2 should be permissive to infection, have the same receptors for viral entry as in humans, and replicate the full spectrum of human COVID-19 disease and pathology.¹⁰⁹ Several publications review and compare common animal models for SARS-CoV-2 and conclude that current models simulate mild infection with full recovery, but not severe COVID-19 disease.^{13,31,52,78,81,100,105} Disease features not expressed in current animal models include ARDS, coagulopathy, systemic sequelae, and mortality.³¹This review will focus on why NHPs provide a valuable model for SARS-CoV-2 research. Using NHPs has several drawbacks as compared with small animal models, including higher purchase cost, limited availability, higher housing cost, larger space requirement, and need for specialized staff. In addition, NHPs are outbred, leading to greater variation in results among individual animals, sometimes making data analysis and interpretation difficult.^40,68 The preexisting shortage of NHPs available for biomedical research, combined with the high demand for COVID-19 research and China’s ban on the sale, transport, and export of NHPs to curtail the spread of COVID-19 (instituted January 26, 2020) has affected NHP research globally.^{3,116,138,141} Nevertheless, the scientific benefits of using NHPs for SARS-CoV-2 research outweigh these drawbacks. NHPs are physiologically, genetically, and immunologically more closely related to humans than are small animals.⁶⁸ Furthermore, the main receptor for SAR-CoV-2 binding, angiotensin l converting enzyme 2 (ACE2), in catarrhines (apes, Asian monkeys, and African monkeys) is identical to the human ACE2 receptor.^24,74 Moreover, like most humans, macaques infected with SARS-CoV-2 develop mild to moderate respiratory disease. Thus, macaques offer a relevant model to study SARS-CoV-2 pathogenesis, therapeutics, vaccines, and the impact of age and other comorbidities on disease outcome.     

Tetrameric Orai1 Is a Teardrop-shaped Molecule with a Long, Tapered Cytoplasmic Domain

The Ca²⁺ release-activated Ca²⁺ channel is a principal regulator of intracellular Ca²⁺ rise, which conducts various biological functions, including immune responses. This channel, involved in store-operated Ca²⁺ influx, is believed to be composed of at least two major components. Orai1 has a putative channel pore and locates in the plasma membrane, and STIM1 is a sensor for luminal Ca²⁺ store depletion in the endoplasmic reticulum membrane. Here we have purified the FLAG-fused Orai1 protein, determined its tetrameric stoichiometry, and reconstructed its three-dimensional structure at 21-Å resolution from 3681 automatically selected particle images, taken with an electron microscope. This first structural depiction of a member of the Orai family shows an elongated teardrop-shape 150Å in height and 95Å in width. Antibody decoration and volume estimation from the amino acid sequence indicate that the widest transmembrane domain is located between the round extracellular domain and the tapered cytoplasmic domain. The cytoplasmic length of 100Å is sufficient for direct association with STIM1. Orifices close to the extracellular and intracellular membrane surfaces of Orai1 seem to connect outside the molecule to large internal cavities.Ca²⁺ is an intracellular second messenger that plays important roles in various physiological functions such as immune response, muscle contraction, neurotransmitter release, and cell proliferation. Intracellular Ca²⁺ is mainly stored in the endoplasmic reticulum (ER).² This ER system is distributed through the cytoplasm from around the nucleus to the cell periphery close to the plasma membrane. In non-excitable cells, the ER releases Ca²⁺ through the inositol 1,4,5-trisphosphate (IP₃) receptor channel in response to various signals, and the Ca²⁺ store is depleted. Depletion of Ca²⁺ then induces Ca²⁺ influx from outside the cell to help in refilling the Ca²⁺ stores and to continue Ca²⁺ rise for several minutes in the cytoplasm (1, 2). This Ca²⁺ influx was first proposed by Putney (3) and was named store-operated Ca²⁺ influx. In the immune system, store-operated Ca²⁺ influx is mainly mediated by the Ca²⁺ release-activated Ca²⁺ (CRAC) current, which is a highly Ca²⁺-selective inwardly rectified current with low conductance (4, 5). Pathologically, the loss of CRAC current in T cells causes severe combined immunodeficiency (6) where many Ca²⁺ signal-dependent gene expressions, including cytokines, are interrupted (7). Therefore, CRAC current is necessary for T cell functions.Recently, Orai1 (also called CRACM1) and STIM1 have been physiologically characterized as essential components of the CRAC channel (8–12). They are separately located in the plasma membrane and in the ER membrane; co-expression of these proteins presents heterologous CRAC-like currents in various types of cells (10, 13–15). Both of them are shown to be expressed ubiquitously in various tissues (16–18). STIM1 senses Ca²⁺ depletion in the ER through its EF hand motif (19) and transmits a signal to Orai1 in the plasma membrane. Although Orai1 is proposed as a regulatory component for some transient receptor potential canonical channels (20, 21), it is believed from the mutation analyses to be the pore-forming subunit of the CRAC channel (8, 22–24). In the steady state, both Orai1 and STIM1 molecules are dispersed in each membrane. When store depletion occurs, STIM1 proteins gather into clusters to form puncta in the ER membrane near the plasma membrane (11, 19). These clusters then trigger the clustering of Orai1 in the plasma membrane sites opposite the puncta (25, 26), and CRAC channels are activated (27).Orai1 has two homologous genes, Orai2 and Orai3 (8). They form the Orai family and have in common the four transmembrane (TM) segments with relatively large N and C termini. These termini are demonstrated to be in the cytoplasm, because both N- and C-terminally introduced tags are immunologically detected only in the membrane-permeabilized cells (8, 9). The subunit stoichiometry of Orai1 is as yet controversial: it is believed to be an oligomer, presumably a dimer or tetramer even in the steady state (16, 28–30).Despite the accumulation of biochemical and electrophysiological data, structural information about Orai1 is limited due to difficulties in purification and crystallization. In this study, we have purified Orai1 in its tetrameric form and have reconstructed the three-dimensional structure from negatively stained electron microscopic (EM) images.