Zika epidemic fast-tracks research funding in Brazil

If the outcome is positive, we may be creating a new way to foster and promote science in Brazil by using a fast-track model for emergencies, says Paolo Zanotto, coordinator of the Zika Network.

By Karina Toledo and Samuel Antenor  |  Agência FAPESP – While Brazilian scientists were preparing for a possible epidemic of chikungunya and developing methods to diagnose the disease quickly, zika virus was spreading almost unheeded. Until recently, zika was considered relatively benign, as its symptoms were seen as milder than those caused by dengue virus.

Attention in Brazil and the world focused on the pathogen first discovered in Uganda’s Zika Forest only when a possible link with the surge in cases of microcephaly in Northeast Brazil emerged in 2015.

The fact that the zika epidemic took Brazil by surprise may have at least one positive effect: the creation of mechanisms to streamline the funding of scientific research. This is the view of Paolo Zanotto, a professor at the University of São Paulo’s Biomedical Science Institute (ICB-USP). Last December, Zanotto helped set up the Zika Network, a task force to research and combat the virus in São Paulo State.

According to Zanotto, in December 2015, when FAPESP approved additional funding for ongoing projects in a matter of days so that part of their activities could be redirected to support for the emergency response to the zika epidemic, the move triggered a chain reaction among other research funding agencies in Brazil.

“The Ministry of Education’s Office for Faculty Development, CAPES, saw what FAPESP did to approve extra funding for existing projects quickly and realized this shortens induction time by irrigating with funds what needs to be pushed forward. So, CAPES is also endeavoring to expedite the process. The Ministry of Science, Technology & Innovation, MCTI, aims to follow suit by fast-tracking funding to the various state research agencies, FAPs, and the National Science & Technology Institutes, INCTs. In other words, everyone understands there’s no time to lose”, Zanotto said.

If at the end of the experience the balance is positive, the outcome may be a new fast-track model for emergencies and the acceleration of research and development processes.

“When we have exponential problems, the responses have to be exponential, and the managers of science and health in Brazil have begun to understand this,” Zanotto said.

In an interview given to Agência FAPESP, Zanotto commented on this and other topics relating to the growth in cases of zika and microcephaly in Brazil.

Agência FAPESP – Which research themes have been prioritized by the Zika Network?
Paolo Zanotto – Our vision is similar to those of the European Union and the US National Institutes of Health, NIH: the overriding goal at this time is the creation of rapid diagnostic tools so that zika virus can be distinguished from other arboviruses like dengue. The nucleic acid part, involving a PCR assay to detect blood viral DNA during the acute phase, is very well developed, but we need serological diagnosis to detect antibodies against the virus even after the acute phase. The second priority is to understand the link with microcephaly. These are the top two goals in terms of urgency. After that, there are other important aspects, such as the development of a vaccine, entomological studies to understand the mosquito’s genetics and how it infects people, and associated research on biological control. BR3, a startup incubated by the University of São Paulo’s Center for Innovation, Entrepreneurship & Technology (CIETEC-USP), is working with Bacillus thuringiensis israelensis, Bti, a bacterium whose spores contain four toxins that are lethal to Aedes. This has been known since the 1980s, but no one could find a way to assure the spores’ survival in the environment. BR3 has created a structure it calls a bio-hut, a pastille you throw into water where the Aedes larvae are breeding and it sinks to the bottom and forms a sort of igloo, which gradually releases the spores. With the right amount of pastilles, approximately 50% of the larvae die in the first five hours, and after that 100% lethality is maintained for 120 days. But the main problem with biological control, which includes the production of genetically modified (GM) mosquitoes, is scale. We don’t yet have the capacity to produce material on a large enough scale to meet demand. Another important part of what the Zika Network is doing is tracking the spread of the virus. We plan to isolate circulating viruses, sequence them, and then measure the evolutionary distance between them in a family tree to find out where they come from. There’s also human genetics, which means investigating factors that may influence the severity of the disease. The last task, which is crucial from the public health standpoint, is the monitoring of case-control cohorts: as soon as a gestation is confirmed, we test for zika virus and keep tabs on the mother and fetus to see what happens. This is being done in several cities in São Paulo State, such as Jundiaí, São José do Rio Preto, Ribeirão Preto and São Paulo. If any of these pregnant women are infected, the monitoring method changes. Once we’ve had a few complete pregnancy cycles in these cohorts, we’ll start to get a better grip on assessing the risk of bearing a child with microcephaly for a mother infected with zika, for example. This risk may be influenced by genetic factors or exposure to other agents, other viruses, during pregnancy.

Agência FAPESP – Has the link between zika virus and microcephaly been confirmed? Do we know how the virus affects the nervous system?
Zanotto – The announcement made by the World Health Organization, WHO, suggested the virus is guilty until proven innocent. That’s extremely rational but inverts the way science works. We typically try to establish a causal relationship first and only then determine what happens at the level of process. What we’re trying to do now is apply zika virus to an animal model and show that a disease equivalent to microcephaly develops only as a result of exposure to the virus. The next step is to infect nervous system cells to see whether the virus alone causes a certain kind of cell death. We then drill deeper into the problem to understand the role played by zika in tissue. That’s how science proceeds. However, in an emergency with high risk you may have to do things in the reverse order. When lives are at risk, you have to decide how to act, and you may have to assume the virus is guilty until proven innocent. There’s a very good overlap between cases of zika and then microcephaly in space and time, both in French Polynesia and in Brazil. In any event, the presence of zika in the brain of an aborted fetus with microcephaly has been demonstrated.

Agência FAPESP – Are the microcephaly cases that are being associated with zika virus similar to those associated with cytomegalovirus (CMV), syphilis and other diseases?
Zanotto – Zika virus appears to display a pattern of its own, with certain characteristics similar to those of infection by parvovirus B19, which causes erythema infectiosum, such as tissue calcifications. There are also similar factors to those observed in CMV infection, such as nervous system liquefaction in late pregnancy. The nervous system tissue is apparently destroyed in the seventh or eighth month. The cortex, the upper brain, practically disappears. In the cases we’re monitoring, we have proof that there’s been no CMV infection. We take into consideration all risk factors for congenital malformation.

Agência FAPESP – Are infected young children also susceptible to neurological damage?
Zanotto – There’s no evidence of that, but we must keep a good lookout because of the demographic factor. As more people are infected, severe manifestations start to be observed. I can’t say no with certainty.

Agência FAPESP – Is there a period during pregnancy when infection can be more harmful?
Zanotto – I’ve talked to pediatricians and obstetricians in Recife, and there does seem to be certain critical stages of brain development. Around 29 weeks, the neural progenitor cells start differentiating into neurons very quickly, and these neurons starting constructing synapses with other neurons. At the same time, the neurons that aren’t building synapses start to suffer apoptosis, programmed cell death. We’re deducing from observations of multiple cases that the 29th week is important. This needs to be studied in more detail so we can determine the window of time we have to administer therapy, for example. Initially, we had an idea that some event happening in the first trimester of pregnancy might be most dangerous. Then, we began to see reports of women submitted to morphometric examination in the sixth and seventh month, and apparently there were no problems with the fetuses. All of a sudden, the brain literally melted. We also know that a woman can be infected in the first trimester of pregnancy and then fetal complications appear much later. We need to find out how this delayed damage occurs.

Agência FAPESP – Do you believe there’s any link between microcephaly and the measles vaccine or between the zika outbreak and transgenic mosquitoes, as has been rumored on social media?
Zanotto – The idea that the outbreak of zika is associated with GM mosquitoes is an interesting urban legend. It’s pseudo-scientific to some extent, but don’t forget these GM mosquitoes are male, and the male doesn’t carry the virus. Males don’t infect anyone: they don’t bite and feed only on flowers. So, that story makes no sense. The other idea, about the measles vaccine, is also false because it completely ignores certain fundamental epidemiological issues. It’s important to note the matter of space and time. The vaccines used in French Polynesia and Brazil weren’t from the same batches. And, in the one case of microcephaly recorded in São Paulo, we have the patient history: the baby attended the same local health clinic from birth, so we know which vaccines were administered and when. In the case of dengue outbreaks, for example, you have a transmission gradient. To prove a link between microcephaly and the measles vaccine, you would have to show that the same batch was taken from Pernambuco to Sergipe to Bahia and then to São Paulo, in the same pattern as the cases that are being reported, and that’s just not happening. If we look at the pattern of microcephaly or Guillain-Barré syndrome in New Caledonia, French Polynesia and Brazil, the reported cases reflect viral transmission. All you need is common sense and lucid arguments to refute these claims.

Agência FAPESP – What is known about other possible forms of contagion aside from being bitten by mosquitoes of the genus Aedes?
Zanotto – Two cases of transmission by blood transfusion have been identified in Campinas. The virus can be detected more easily in saliva than in blood. In urine, it persists for longer than in blood. But, no cases of transmission by saliva or urine have yet been confirmed. Three reported cases are strongly associated with sexual transmission. They’re people who traveled to countries where there are cases of zika, had symptoms on returning to their countries of origin, where there are no vectors, and infected a partner. So, sexual transmission is possible. But, we have to try to gauge the importance of this from the epidemiological standpoint. If it’s an important factor, we’re in a completely different situation. It could also be an exception, a factor that doesn’t significantly affect the overall dynamics of transmission.

Agência FAPESP – Do you think the fact that the Olympic Games will be held in Brazil this year could contribute to the worldwide spread of zika virus?
Zanotto – I’m of two minds about that. Like the FIFA World Cup held in Brazil in 2014, the Olympic Games will take place during winter in the southern hemisphere, and at lower temperatures it’s harder for the vector population to remain sufficiently numerous to sustain outbreaks. Of course, this doesn’t apply to the Northeast and North of Brazil, where it’s always very warm. People are also bitten much less in winter than in summer, and this is directly linked to the probability of infection. However, this is not a typical year weather-wise because of El Niño: there’s been a lot of rain and temperatures have fluctuated. This is a factor that should be considered. Another very important point is whether the virus is using only Aedes aegypti as a vector in Brazil. A. albopictus and/or other mosquito species may also be vectors now. These studies started only a short time ago.

Agência FAPESP – Is there any evidence that the southern house mosquito or some other insect can transmit zika virus?
Zanotto – In the flavivirus family tree, there’s a group that’s vectored by Culex, the genus to which the peridomestic mosquito belongs, including Japanese encephalitis virus, West Nile virus and Saint Louis encephalitis virus. The Aedes-borne viruses, including zika, dengue and yellow fever, are in another branch of the family. In the case of dengue, there’s no evidence of transmission by Culex, so I wouldn’t expect it to be a problem in the case of zika. However, we should test for that. On the other hand, A. albopictus could be a vector. This is one of the prime concerns for the northern hemisphere. It could spread the virus all over the Americas and then jump over the Pyrenees and Alps in Europe.

Agência FAPESP – Why do outbreaks of dengue, zika and other arboviruses get worse in warm weather?
Zanotto – The Aedes mosquito’s metabolism accelerates as the ambient temperature rises. A rise of 5 degrees Celsius can double the speed at which it reproduces and make it produce more viruses in less time. But, zika is a zoonosis with atypical behavior. In Senegal, its presence has been observed throughout the year for a decade now. Researchers in Africa are investigating the mechanism underlying this maintenance. It might be vertical transmission, when the female mosquito lays eggs already infected with the virus, or there may be viral reservoirs with more rapid reproduction cycles that aren’t being detected. In Africa, there are several species of Aedes infected with zika virus, and we’ve realized that the pathogen adapts rapidly to each vector. It’s a highly plastic virus with the adaptive capacity to become pandemic.

Agência FAPESP – Does Brazil have the conditions to control Aedes right now?
Zanotto – The health minister was criticized for saying Brazil is losing the war against Aedes, but the truth is the world’s losing the war. If we look at the mosquito’s distribution around the globe, we see it has conquered the entire equatorial and tropical part of the planet. This is a global problem that includes the most advanced countries. It may be possible to think of eliminating the vector, but the right approach is to work on control in places where infestation can be significantly reduced because less infestation means fewer outbreaks. This is what happened, for example, in Guarujá in 2013, when we detected breeding grounds and intervened, collapsing the outbreak caused by serotype 4 dengue virus. There are ways of intervening in real time, detecting viremic people and their spatial locations, creating local mechanisms for action. It’s expensive, but the cost of not doing it is higher. So, there are mechanisms that can be implemented locally, but they involve private enterprise, academia, government, and society.

Agência FAPESP – In addition to the four viruses most associated with Aedes, can it transmit others such as Mayaro and Oropouche?
Zanotto – Yes, those viruses are present in Brazil and fairly well distributed. Altogether, there are 2 million types of fever that occur in the Amazon region, and they aren’t well understood. The number of agents is enormous. Aedes and its proximity to the other viruses that came from Africa could lead us to have to deal in the future with an immense list of viruses, some of which are extremely dangerous. Many of these viruses have been studied a great deal. Our experience with zika will be most useful for research to be developed as part of a collaboration between the University of São Paulo, Fiocruz and the Pasteur Institute, which actually has an area allocated on the university’s campus in the city of São Paulo. One of the ways we’re going to collaborate with the African group will be to start proactively setting up molecular and serological detection platforms that target these viruses in Brazil. If we had prepared for zika ten years ago, the story might have been different. We need to learn from this situation. In response to what’s happening, we’ve changed our understanding of the importance of tracking viruses proactively, even if they aren’t present in Brazil.

Agência FAPESP – In the case of chikungunya, which has already caused deaths in Brazil, is there a possibility of an outbreak as large as the zika outbreak?
Zanotto – We were more prepared for chikungunya, for example, than for zika. Commercial methods for detecting chikungunya are available. Partly, that’s because the symptoms caused by the virus are much more severe. Seven months ago, it was believed that zika wouldn’t be a problem because most cases are asymptomatic. Microcephaly has totally changed the level of severity of this agent. We know about interactions between chikungunya and zika, about co-circulation and overlapping in various parts of Asia and the Pacific. So, we need to understand all this better.

Agência FAPESP – If most manifestations of zika aren’t noticed, how should a pregnant woman respond to this information? Is it possible to imagine a test as part of antenatal care?
Zanotto – Right now, we have a piece of the virus’s protein that’s useful to distinguish zika from the other flaviviruses. This material is now arriving from Africa and being synthesized by Luis Carlos Ferreira, a professor at ICB-USP, who is starting to produce proteins in bacteria to test the reaction of serum from our patients infected by zika. If all goes well, we may soon have a system for rapid immunological testing. And, this could be extremely important, enabling pregnant women to know during antenatal care whether they have ever been infected by zika. The confusion will gradually go away, thanks to rapid progress here in São Paulo State, including blood banks already reporting the presence of the virus (read more at http://agencia.fapesp.br/22760/). Until we have a simple, rapid test that distinguishes zika from other arboviruses, we’re forced to use a test that takes longer and seroneutralization, in which we infect cells with the virus and serum taken from patients – if it neutralizes the infection, that means they’ve been infected by zika. We’ve performed many confirmations in academic terms, but we can’t yet do this on a mass scale for the entire population. The arrival of these peptides and their production at USP can help us create rapid diagnostic tests for all.

Agência FAPESP – Does the visibility this gives the actors involved make Brazilian research better known internationally?
Zanotto – There are two ways of measuring our international standing in this field. One is scientific production, which depends on access to physical and other resources so that we can perform the scientific research. There are difficulties, but we’re getting organized. The National Public Health Surveillance Agency, ANVISA, is assisting us by facilitating imports of resources and materials such as reagents. So, that’s going well. We have enormous potential to perform scientific research in São Paulo State. On the other hand, there’s a second crucial component, which is control of the epidemic. The fact that we’re producing these two components, scientific knowledge and control, is important. Brazil will make a significant contribution, not least because this is where most of the cases exist. Currently, I can see from the various proposals that are being put forward the types of interaction, the European Union funding, the NIH funding, that they’re taking this aspect into account, the fact that they have partners here, which is very good for all concerned. As for our stance, we’re offering partnership and collaboration. The Brazilian scientific community is well developed and has the capacity to handle all this successfully, with a good structure, efficient research institutions, sufficient funding, effective networking among institutions, and good international relations, which are necessary for certain fundamental solutions to move forward.

Agência FAPESP – What has been done to accelerate research on the zika epidemic?
Zanotto – We’re keeping track of several cases of microcephaly in São Paulo, and we plan to conduct basic research totally inserted in the context of almost immediate public utility. Anything we find that’s potentially useful must be made available, as it could improve the diagnosis and care of pregnant women. For example, the Ministry of Education’s Office for Faculty Development, CAPES, saw what FAPESP did to approve extra funding for existing projects quickly and realized this shortens induction time by irrigating with funds what needs to be pushed forward. So, CAPES is also endeavoring to expedite the process. The Ministry of Science, Technology & Innovation, MCTI, aims to follow suit by fast-tracking funding to the various state research agencies, FAPs, and the National Science & Technology Institutes, INCTs. In other words, everyone understands there’s no time to lose. If we had to do all this by the book, too much time would be wasted. CAPES is aware of this and also wants to fast-track approval. FAPESP’s move triggered a chain reaction by other research-funding agencies around the country. That’s very important because it has created mechanisms to speed things up. If it all works out and at the end of this experience we have a positive result, we may be creating a new way to foster and promote science in Brazil. When we have exponential problems, the responses have to be exponential, and the managers of science and health in Brazil have begun to understand this.