Biologist Rafaela Rosa-Ribeiro is a postdoctoral fellow at the Instituto Israelita de Ensino e Pesquisa Albert Einstein, where she studies – with support from Fapesp – cell death pathways induced by the Zika virus in various types of cells.
In 2019, he started a research internship at the Department of Infectious Diseases and Neuroscience at Ospedalle San Rafaelle – hospital located in Milan, Italy. The project is supervised by Elisa Vicenzi, coordinator of the first Italian group – and the second in the world – that isolated SARS-CoV, a virus that emerged in 2002 in China, where it caused the first cases of SARS, the severe acute respiratory syndrome.
SARS-CoV has spread to about 30 countries, infected more than 8,000 people and caused about 800 deaths. However, since 2004, no new cases of SARS have been reported. Now, in the face of the emergence of a new coronavirus —The SARS-CoV-2, which causes covid-19— the Vicenzi group is beginning studies aimed at testing drugs that have shown potential in previous tests to fight respiratory viruses.
Another line of investigation aims to understand which signaling pathways are activated in cells infected with SARS-CoV-2. Experiments will be carried out with human cells and also with bats, animals considered to be reservoirs of several species of coronavirus and that do not develop symptoms of the infection.
In an interview with Agencia Fapesp, Rosa-Ribeiro presented a scope of the projects that will be carried out in Italy during the coming weeks and told how the experience of dealing with the epidemic has been. According to the Official Repository of the Italian Civil Protection Department, since February 24, 27,980 cases of covid-19 and 2,158 deaths have been confirmed. About 12,876 people were hospitalized and 1,851 needed intensive care. Between March 15 and March 16, there were 2,470 new positive cases.
Agencia FAPESP – You went to Italy to develop a project on the Zika virus, but now you are also involved in studies on the new coronavirus. Will the two projects be conducted in parallel?
Rafaela Rosa-Ribeiro – Yes, I couldn’t pass up the opportunity. Our research group is small. We are five people and students are not able to come to the hospital. As a postdoc, I am supporting everything I can. I ended up getting involved in the idealization of some studies on the new coronavirus. Of course, Zika research is my priority, but some facilities are not working and then you will have to wait for all of this to pass to continue the experiments. Italy is really stuck, it is impressive. In the meantime, I will take the opportunity to map as much information as possible about the new coronavirus.
Agencia FAPESP – What studies are being started on SARS-CoV-2?
Rosa-Ribeiro – Are two. In partnership with pharmaceutical companies we are going to test some drugs against the virus. On another front, we will evaluate in vitro how the virus infects macrophages and monocytes, two types of immune cells. We are already isolating viruses from different patients to have a stock in the laboratory. We will soon begin to isolate cells from both infected people and healthy individuals. We want to see what response is activated in these cells after infection. How gene expression changes, which cytokines [proteínas que atuam como sinalizadores do sistema imune] are released. The idea is to map the cell death signaling pathways triggered by the virus. My Zika project also focuses on cell death signaling pathways.
Agencia FAPESP – Why is it important to study cell death signaling pathways?
Rosa-Ribeiro – To understand the mechanism of the disease and identify targets for possible interventions. When cell death occurs, virus replication is inhibited. We need to know if the cell can start the process of cell death easily or if the virus has mechanisms to inhibit it, as does the herpes virus, for example. In addition, there are several different types of cell death. Some are ‘silent’, as is the case with apoptosis. Others cause cell content to leak and induce a strong inflammatory reaction. On the one hand this is bad, as it causes damage to the tissue, but on the other hand it alerts the immune system, which sends more defense cells to the site. By understanding what happens during infection with the new coronavirus, we can identify important signaling pathways to be modulated by a drug, for example. In addition, we will also study what happens when the virus infects bat cells. These animals are reservoirs for several species of coronavirus, but do not develop symptoms. Perhaps this is because the virus-activated signaling pathways in bats are different. It is something we want to understand.
Agencia FAPESP – Will the drug study be in vitro or in vivo? Will both be conducted in parallel?
Rosa-Ribeiro – Yes, unfortunately everything will have to be done very quickly. All studies will be in vitro, we still don’t have plans to use animal models. There are some drugs that have shown the potential to fight respiratory viruses, including the cause of SARS. My supervisor took part in some of these studies in the past, but when SARS-CoV stopped circulating, investments in research decreased. Now we have to practically start over from scratch.
Agencia FAPESP – Why did Italy take time to sequence the viral genomes of infected patients?
Rosa-Ribeiro – Italy is an even more bureaucratic country than Brazil. Here it is not allowed to use samples collected for diagnosis in research, even if the patient authorizes it. First, you must obtain approval from an ethics committee. The first samples from Italy were concentrated in Rome, in a government institution responsible for countering positive cases. It took them a long time to get authorization to do the sequencing. In addition, this institution did not have access to the technology that allows fast sequencing, as was done in Brazil. They sequenced by the traditional method, which takes longer. There are now about five genomes sequenced here in Italy.
Agencia FAPESP – And based on these genomes, is it possible to reach any conclusions?
Rosa-Ribeiro – If we look at all the sequenced genomes together, there seems to be a European cluster – which gathers samples from Italy, Germany, France, the Netherlands and also the two from Brazil [de pessoas infectadas na Europa]- another Chinese and a third North American cluster. But these are very small differences, nothing capable of altering the virus’s ability to infect cells, for example. Now that there is community broadcasting in Brazil, it will be necessary to sequence more samples to see what the country’s profile will be like.
Agencia FAPESP – Is it possible to trace the history of the epidemic in Italy?
Rosa-Ribeiro – No. The zero patient – within the first cases of community transmission in the country – was not identified. We know that patient-one sought help in a hospital and, even with symptoms, was not tested at first and was released. This is because the guidance of WHO (World Health Organization) at the time was to test only those who had a history of traveling to a country at risk or of contact with people who were in those countries. This patient was seen in early February in the city of Codogno [a cerca de 60 quilômetros de Milão].
When community transmission was identified, there was no quick block in the region. Activities gradually stopped. First, 11 cities in the Lombardy region were isolated, this was at the time of Carnival. The rest of the northern region maintained its routine for a week and a half. It was recommended only for people to keep one meter away from each other and stay home if they had symptoms. When it was decided to isolate the entire northern region, the situation was already very complicated. The next day, the whole country went into isolation. The recommendation that we can give based on this experience is that, as soon as an outbreak of the disease is identified, measures should be taken immediately to decrease the circulation of people. Close schools, universities, bars, restaurants, cancel shows and events, avoid trips and avoid public transport. The symptoms will be mild for 80% of those infected, but people need to be aware that by circulating around the city they help spread the virus. If many people become infected in a short period of time, the possibility of many severe cases arising simultaneously increases and the health system will not cope. Hand washing and restricting the movement of people are the only effective measures.
Agencia FAPESP – What is the situation today in Italian hospitals?
Rosa-Ribeiro – Here at Ospedale San Raffaele, they got donations to make a new, half-prefabricated wing to allocate patients with covid-19. But the health system as a whole is overburdened, especially in the northern region. The fatality rate in the country is 7.3%, as only serious cases are reaching hospitals. Health professionals are having to choose who to treat, as there is no ventilation equipment and ICUs [Unidades de Terapia Intensiva] enough for everyone.
Agencia FAPESP – Is there any expectation about how long the isolation should last?
Rosa-Ribeiro – When they closed the entire northern region, they spoke in a month and two weeks have passed. But there are many doctors infected and there is a lack of teams to care for patients with covid-19, as well as the injured and those with other diseases. Even residents, who were initially dismissed to avoid contamination, were recruited. Today it is known that the process of intubating severely ill patients causes many aerosols containing the virus to spread throughout the hospital. We were learning as everything happened.
Agencia FAPESP – What is the protocol today?
Rosa-Ribeiro – Now the infected patients are in an isolated area and everyone who deals with them looks like astronauts. They must remove their protective clothing before traveling to other areas of the hospital. Everyone is wearing a mask, even secretaries, porters and people on the streets. Laboratories are working with only 10% of the workforce. Today the tests are only applied to people with severe symptoms to confirm the diagnosis before admission. Those with mild symptoms are advised to stay at home. You can receive a visit from the family doctor – a service offered by the public health system – or receive guidance on which medicine to take to relieve symptoms.
Agencia FAPESP – Have you talked about what will be done after the peak of the epidemic passes?
Rosa-Ribeiro – For now the concern is still to put out the fire, but we know that the damage will be great. In Brazil there is an exorbitant social class difference and people with less conditions often cannot stop working. Whoever can stay at home should stay. I haven’t seen my friends for two weeks and I have no family here. In the first week of isolation, I spent five days without seeing anyone. It is a very heavy climate.