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Mia ME, Howlader M, Akter F, Hossain MM. Preclinical and Clinical Investigations of Potential Drugs and Vaccines for COVID-19 Therapy: A Comprehensive Review With Recent Update. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2024; 17:2632010X241263054. [PMID: 39070952 PMCID: PMC11282570 DOI: 10.1177/2632010x241263054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 06/03/2024] [Indexed: 07/30/2024]
Abstract
The COVID-19 pandemic-led worldwide healthcare crisis necessitates prompt societal, ecological, and medical efforts to stop or reduce the rising number of fatalities. Numerous mRNA based vaccines and vaccines for viral vectors have been licensed for use in emergencies which showed 90% to 95% efficacy in preventing SARS-CoV-2 infection. However, safety issues, vaccine reluctance, and skepticism remain major concerns for making mass vaccination a successful approach to treat COVID-19. Hence, alternative therapeutics is needed for eradicating the global burden of COVID-19 from developed and low-resource countries. Repurposing current medications and drug candidates could be a more viable option for treating SARS-CoV-2 as these therapies have previously passed a number of significant checkpoints for drug development and patient care. Besides vaccines, this review focused on the potential usage of alternative therapeutic agents including antiviral, antiparasitic, and antibacterial drugs, protease inhibitors, neuraminidase inhibitors, and monoclonal antibodies that are currently undergoing preclinical and clinical investigations to assess their effectiveness and safety in the treatment of COVID-19. Among the repurposed drugs, remdesivir is considered as the most promising agent, while favipiravir, molnupiravir, paxlovid, and lopinavir/ritonavir exhibited improved therapeutic effects in terms of elimination of viruses. However, the outcomes of treatment with oseltamivir, umifenovir, disulfiram, teicoplanin, and ivermectin were not significant. It is noteworthy that combining multiple drugs as therapy showcases impressive effectiveness in managing individuals with COVID-19. Tocilizumab is presently employed for the treatment of patients who exhibit COVID-19-related pneumonia. Numerous antiviral drugs such as galidesivir, griffithsin, and thapsigargin are under clinical trials which could be promising for treating COVID-19 individuals with severe symptoms. Supportive treatment for patients of COVID-19 may involve the use of corticosteroids, convalescent plasma, stem cells, pooled antibodies, vitamins, and natural substances. This study provides an updated progress in SARS-CoV-2 medications and a crucial guide for inventing novel interventions against COVID-19.
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Affiliation(s)
- Md. Easin Mia
- Department of Biotechnology and Genetic Engineering, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Mithu Howlader
- Department of Biotechnology and Genetic Engineering, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Farzana Akter
- Department of Biotechnology and Genetic Engineering, Noakhali Science and Technology University, Noakhali, Bangladesh
| | - Md. Murad Hossain
- Department of Biotechnology and Genetic Engineering, Noakhali Science and Technology University, Noakhali, Bangladesh
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2
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Dang X, Yu Z, Wang X, Li N. Eco-Friendly Cellulose-Based Nonionic Antimicrobial Polymers with Excellent Biocompatibility, Nonleachability, and Polymer Miscibility. ACS APPLIED MATERIALS & INTERFACES 2023; 15:50344-50359. [PMID: 37862609 DOI: 10.1021/acsami.3c10902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
This study aims to prepare natural biomass-based nonionic antimicrobial polymers with excellent biocompatibility, nonleachability, antimicrobial activity, and polymer miscibility. Two new cellulose-based nonionic antimicrobial polymers (MIPA and MICA) containing many terminal indole groups were synthesized using a sustainable one-pot method. The structures and properties of the nonionic antimicrobial polymers were characterized using nuclear magnetic resonance hydrogen spectroscopy (1H NMR), infrared spectroscopy (FTIR), wide-angle X-ray diffractometry (XRD), thermogravimetric analysis (TGA), differential scanning calorimetry (DSC), scanning electron microscopy (SEM), gel chromatography (GPC), and other analytical techniques. The results showed that microcrystalline cellulose (MCC) molecules combined with indole derivatives through an esterification reaction to produce MICA and MIPA. The crystallinity of the prepared MICA and MIPA molecules decreased after MCC modification; their morphological structure changed from short fibrous to granular and showed better thermal stability and solubility. The paper diffusion method showed that both nonionic polymers had good bactericidal effects against the two common pathogenic bacteria Escherichia coli (E. coli, inhibition zone diameters >22 mm) and Staphylococcus aureus (S. aureus, inhibition zone diameters >38 mm). Moreover, MICA and MIPA showed good miscibility with biodegradable poly(vinyl alcohol) (PVA), and the miscible cellulose-based composite films (PVA-MICA and PVA-MIPA) showed good phase compatibility, light transmission, thermal stability (maximum thermal decomposition temperature >300 °C), biocompatibility, biological cell activity (no cytotoxicity), nonleachability, antimicrobial activity, and mechanical properties (maximum fracture elongation at >390%).
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Affiliation(s)
- Xugang Dang
- Institute for Biomass and Function Materials & National Demonstration Centre for Experimental Light Chemistry Engineering Education, College of Bioresources Chemistry and Materials Engineering, Shaanxi University of Science and Technology, Xi'an 710021, P. R. China
- Hubei Provincial Engineering Laboratory for Clean Production and High Value Utilization of Bio-Based Textile Materials, Wuhan Textile University, Wuhan 430200, P. R. China
| | - Zhenfu Yu
- Institute for Biomass and Function Materials & National Demonstration Centre for Experimental Light Chemistry Engineering Education, College of Bioresources Chemistry and Materials Engineering, Shaanxi University of Science and Technology, Xi'an 710021, P. R. China
| | - Xuechuan Wang
- Institute for Biomass and Function Materials & National Demonstration Centre for Experimental Light Chemistry Engineering Education, College of Bioresources Chemistry and Materials Engineering, Shaanxi University of Science and Technology, Xi'an 710021, P. R. China
| | - Nan Li
- Institute for Biomass and Function Materials & National Demonstration Centre for Experimental Light Chemistry Engineering Education, College of Bioresources Chemistry and Materials Engineering, Shaanxi University of Science and Technology, Xi'an 710021, P. R. China
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Singh DD, Han I, Choi EH, Yadav DK. A Clinical Update on SARS-CoV-2: Pathology and Development of Potential Inhibitors. Curr Issues Mol Biol 2023; 45:400-433. [PMID: 36661514 PMCID: PMC9857284 DOI: 10.3390/cimb45010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 01/06/2023] Open
Abstract
SARS-CoV-2 (severe acute respiratory syndrome) is highly infectious and causes severe acute respiratory distress syndrome (SARD), immune suppression, and multi-organ failure. For SARS-CoV-2, only supportive treatment options are available, such as oxygen supportive therapy, ventilator support, antibiotics for secondary infections, mineral and fluid treatment, and a significant subset of repurposed effective drugs. Viral targeted inhibitors are the most suitable molecules, such as ACE2 (angiotensin-converting enzyme-2) and RBD (receptor-binding domain) protein-based inhibitors, inhibitors of host proteases, inhibitors of viral proteases 3CLpro (3C-like proteinase) and PLpro (papain-like protease), inhibitors of replicative enzymes, inhibitors of viral attachment of SARS-CoV-2 to the ACE2 receptor and TMPRSS2 (transmembrane serine proteinase 2), inhibitors of HR1 (Heptad Repeat 1)-HR2 (Heptad Repeat 2) interaction at the S2 protein of the coronavirus, etc. Targeting the cathepsin L proteinase, peptide analogues, monoclonal antibodies, and protein chimaeras as RBD inhibitors interferes with the spike protein's ability to fuse to the membrane. Targeting the cathepsin L proteinase, peptide analogues, monoclonal antibodies, and protein chimaeras as RBD inhibitors interferes with the spike protein's ability to fuse to the membrane. Even with the tremendous progress made, creating effective drugs remains difficult. To develop COVID-19 treatment alternatives, clinical studies are examining a variety of therapy categories, including antibodies, antivirals, cell-based therapy, repurposed diagnostic medicines, and more. In this article, we discuss recent clinical updates on SARS-CoV-2 infection, clinical characteristics, diagnosis, immunopathology, the new emergence of variant, SARS-CoV-2, various approaches to drug development and treatment options. The development of therapies has been complicated by the global occurrence of many SARS-CoV-2 mutations. Discussion of this manuscript will provide new insight into drug pathophysiology and drug development.
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Affiliation(s)
- Desh Deepak Singh
- Amity Institute of Biotechnology, Amity University Rajasthan, Jaipur 303002, India
| | - Ihn Han
- Plasma Bioscience Research Center, Applied Plasma Medicine Center, Department of Electrical & Biological Physics, Kwangwoon University, Seoul 01897, Republic of Korea
- Correspondence: (I.H.); (D.K.Y.); Tel.: +82-2-597-0365 (I.H. & D.K.Y.)
| | - Eun-Ha Choi
- Plasma Bioscience Research Center, Applied Plasma Medicine Center, Department of Electrical & Biological Physics, Kwangwoon University, Seoul 01897, Republic of Korea
| | - Dharmendra Kumar Yadav
- Department of R&D Center, Arontier Co., Seoul 06735, Republic of Korea
- Correspondence: (I.H.); (D.K.Y.); Tel.: +82-2-597-0365 (I.H. & D.K.Y.)
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Niknam Z, Jafari A, Golchin A, Danesh Pouya F, Nemati M, Rezaei-Tavirani M, Rasmi Y. Potential therapeutic options for COVID-19: an update on current evidence. Eur J Med Res 2022; 27:6. [PMID: 35027080 PMCID: PMC8755901 DOI: 10.1186/s40001-021-00626-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/23/2021] [Indexed: 12/14/2022] Open
Abstract
SARS-CoV-2, a novel coronavirus, is the agent responsible for the COVID-19 pandemic and is a major public health concern nowadays. The rapid and global spread of this coronavirus leads to an increase in hospitalizations and thousands of deaths in many countries. To date, great efforts have been made worldwide for the efficient management of this crisis, but there is still no effective and specific treatment for COVID-19. The primary therapies to treat the disease are antivirals, anti-inflammatories and respiratory therapy. In addition, antibody therapies currently have been a many active and essential part of SARS-CoV-2 infection treatment. Ongoing trials are proposed different therapeutic options including various drugs, convalescent plasma therapy, monoclonal antibodies, immunoglobulin therapy, and cell therapy. The present study summarized current evidence of these therapeutic approaches to assess their efficacy and safety for COVID-19 treatment. We tried to provide comprehensive information about the available potential therapeutic approaches against COVID-19 to support researchers and physicians in any current and future progress in treating COVID-19 patients.
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Affiliation(s)
- Zahra Niknam
- Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ameneh Jafari
- Advanced Therapy Medicinal Product (ATMP) Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Ali Golchin
- Department of Clinical Biochemistry and Applied Cell Sciences, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Fahima Danesh Pouya
- Department of Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Mohadeseh Nemati
- Department of Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Mostafa Rezaei-Tavirani
- Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Yousef Rasmi
- Department of Biochemistry, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran.
- Cellular and Molecular Research Center, Urmia University of Medical Sciences, Urmia, Iran.
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5
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Batista CM, Foti L. Anti-SARS-CoV-2 and anti-cytokine storm neutralizing antibody therapies against COVID-19: Update, challenges, and perspectives. Int Immunopharmacol 2021; 99:108036. [PMID: 34371330 PMCID: PMC8330556 DOI: 10.1016/j.intimp.2021.108036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) has been declared by the World Health Organization (WHO) as a pandemic since March 2020. This disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The only available tools to avoid contamination and transmission of this virus are physical distancing, the use of N95 and surgical masks, and hand hygiene. Vaccines are another essential tool to reduce the impact of the pandemic, though these present challenges in terms of production and logistics, particularly in underdeveloped and developing countries. One of the critical early research findings is the interaction of the spike virus protein with the angiotensin-converting enzyme 2 (ACE2) human receptor. Developing strategies to block this interaction has therefore been identified as a way to treat this infection. Neutralizing antibodies (nAbs) have emerged as a therapeutic approach since the pandemic started. Infected patients may be asymptomatic or present with mild symptoms, and others may evolve to moderate or severe disease, leading to death. An immunological phenomenon known as cytokine storm has been observed in patients with severe disease characterized by a proinflammatory cytokine cascade response that leads to lung injury. Thus, some treatment strategies focus on anti-cytokine storm nAbs. This review summarizes the latest advances in research and clinical trials, challenges, and perspectives on antibody-based treatments (ABT) as therapies against COVID-19.
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Affiliation(s)
| | - Leonardo Foti
- Laboratory of Trypanosomatids Molecular and Systemic Biology, Brazil.
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6
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King HAD, Joyce MG, Lakhal-Naouar I, Ahmed A, Cincotta CM, Subra C, Peachman KK, Hack HR, Chen RE, Thomas PV, Chen WH, Sankhala RS, Hajduczki A, Martinez EJ, Peterson CE, Chang WC, Choe M, Smith C, Headley JA, Elyard HA, Cook A, Anderson A, Wuertz KM, Dong M, Swafford I, Case JB, Currier JR, Lal KG, Amare MF, Dussupt V, Molnar S, Daye SP, Zeng X, Barkei EK, Alfson K, Staples HM, Carrion R, Krebs SJ, Paquin-Proulx D, Karasavvas N, Polonis VR, Jagodzinski LL, Vasan S, Scott PT, Huang Y, Nair MS, Ho DD, de Val N, Diamond MS, Lewis MG, Rao M, Matyas GR, Gromowski GD, Peel SA, Michael NL, Modjarrad K, Bolton DL. Efficacy and breadth of adjuvanted SARS-CoV-2 receptor-binding domain nanoparticle vaccine in macaques. Proc Natl Acad Sci U S A 2021; 118:e2106433118. [PMID: 34470866 PMCID: PMC8463842 DOI: 10.1073/pnas.2106433118] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Emergence of novel variants of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) underscores the need for next-generation vaccines able to elicit broad and durable immunity. Here we report the evaluation of a ferritin nanoparticle vaccine displaying the receptor-binding domain of the SARS-CoV-2 spike protein (RFN) adjuvanted with Army Liposomal Formulation QS-21 (ALFQ). RFN vaccination of macaques using a two-dose regimen resulted in robust, predominantly Th1 CD4+ T cell responses and reciprocal peak mean serum neutralizing antibody titers of 14,000 to 21,000. Rapid control of viral replication was achieved in the upper and lower airways of animals after high-dose SARS-CoV-2 respiratory challenge, with undetectable replication within 4 d in seven of eight animals receiving 50 µg of RFN. Cross-neutralization activity against SARS-CoV-2 variant B.1.351 decreased only approximately twofold relative to WA1/2020. In addition, neutralizing, effector antibody and cellular responses targeted the heterotypic SARS-CoV-1, highlighting the broad immunogenicity of RFN-ALFQ for SARS-CoV-like Sarbecovirus vaccine development.
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Affiliation(s)
- Hannah A D King
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - M Gordon Joyce
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Ines Lakhal-Naouar
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
- Diagnostics and Countermeasures Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Aslaa Ahmed
- Viral Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Camila Macedo Cincotta
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
- Diagnostics and Countermeasures Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Caroline Subra
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Kristina K Peachman
- Diagnostics and Countermeasures Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Holly R Hack
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
- Diagnostics and Countermeasures Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Rita E Chen
- Department of Medicine, Washington University, St. Louis, MO 63130
- Department of Pathology & Immunology, Washington University, St. Louis, MO 63130
| | - Paul V Thomas
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Wei-Hung Chen
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Rajeshwer S Sankhala
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Agnes Hajduczki
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Elizabeth J Martinez
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Caroline E Peterson
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - William C Chang
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Misook Choe
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Clayton Smith
- Center for Molecular Microscopy, Center for Cancer Research, National Cancer Institute, NIH, Frederick, MD 21702
| | - Jarrett A Headley
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | | | | | - Alexander Anderson
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Kathryn McGuckin Wuertz
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Ming Dong
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Isabella Swafford
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - James B Case
- Department of Medicine, Washington University, St. Louis, MO 63130
| | - Jeffrey R Currier
- Viral Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Kerri G Lal
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Mihret F Amare
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Vincent Dussupt
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Sebastian Molnar
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Sharon P Daye
- Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Xiankun Zeng
- Division of Pathology, US Army Medical Research Institute of Infectious Diseases, Frederick, MD 21702
| | - Erica K Barkei
- Veterinary Pathology Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Kendra Alfson
- Disease Intervention and Prevention, Texas Biomedical Research Institute, San Antonio, TX 78227
| | - Hilary M Staples
- Disease Intervention and Prevention, Texas Biomedical Research Institute, San Antonio, TX 78227
| | - Ricardo Carrion
- Disease Intervention and Prevention, Texas Biomedical Research Institute, San Antonio, TX 78227
| | - Shelly J Krebs
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Dominic Paquin-Proulx
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Nicos Karasavvas
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
- Diagnostics and Countermeasures Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Victoria R Polonis
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Linda L Jagodzinski
- Diagnostics and Countermeasures Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Sandhya Vasan
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
| | - Paul T Scott
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Yaoxing Huang
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY 10032
| | - Manoj S Nair
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY 10032
| | - David D Ho
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY 10032
| | - Natalia de Val
- Center for Molecular Microscopy, Center for Cancer Research, National Cancer Institute, NIH, Frederick, MD 21702
| | - Michael S Diamond
- Department of Medicine, Washington University, St. Louis, MO 63130
- Department of Pathology & Immunology, Washington University, St. Louis, MO 63130
- Department of Molecular Microbiology, Washington University, St. Louis, MO 63130
| | | | - Mangala Rao
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Gary R Matyas
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Gregory D Gromowski
- Viral Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Sheila A Peel
- Diagnostics and Countermeasures Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Nelson L Michael
- Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910
| | - Kayvon Modjarrad
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910;
| | - Diane L Bolton
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD 20910;
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817
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7
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Alamri SS, Alluhaybi KA, Alhabbab RY, Basabrain M, Algaissi A, Almahboub S, Alfaleh MA, Abujamel TS, Abdulaal WH, ElAssouli MZ, Alharbi RH, Hassanain M, Hashem AM. Synthetic SARS-CoV-2 Spike-Based DNA Vaccine Elicits Robust and Long-Lasting Th1 Humoral and Cellular Immunity in Mice. Front Microbiol 2021; 12:727455. [PMID: 34557174 PMCID: PMC8454412 DOI: 10.3389/fmicb.2021.727455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/30/2021] [Indexed: 12/30/2022] Open
Abstract
The ongoing global pandemic of coronavirus disease 2019 (COVID-19) calls for an urgent development of effective and safe prophylactic and therapeutic measures. The spike (S) glycoprotein of severe acute respiratory syndrome-coronavirus (SARS-CoV-2) is a major immunogenic and protective protein and plays a crucial role in viral pathogenesis. In this study, we successfully constructed a synthetic codon-optimized DNA-based vaccine as a countermeasure against SARS-CoV-2, denoted VIU-1005. The design was based on a codon-optimized coding sequence of a consensus full-length S glycoprotein. The immunogenicity of the vaccine was tested in two mouse models (BALB/c and C57BL/6J). Th1-skewed systemic S-specific IgG antibodies and neutralizing antibodies (nAbs) were significantly induced in both models 4 weeks after three injections with 100 μg of the VIU-1005 vaccine via intramuscular needle injection but not intradermal or subcutaneous routes. Such immunization induced long-lasting IgG and memory T cell responses in mice that lasted for at least 6 months. Interestingly, using a needle-free system, we showed an enhanced immunogenicity of VIU-1005 in which lower or fewer doses were able to elicit significantly high levels of Th1-biased systemic S-specific immune responses, as demonstrated by the significant levels of binding IgG antibodies, nAbs and IFN-γ, TNF and IL-2 cytokine production from memory CD8+ and CD4+ T cells in BALB/c mice. Furthermore, compared to intradermal needle injection, which failed to induce any significant immune response, intradermal needle-free immunization elicited a robust Th1-biased humoral response similar to that observed with intramuscular immunization. Together, our results demonstrate that the synthetic VIU-1005 candidate DNA vaccine is highly immunogenic and capable of inducing long-lasting Th1-skewed humoral and cellular immunity in mice. Furthermore, we show that the use of a needle-free system could enhance the immunogenicity and minimize doses needed to induce protective immunity in mice, supporting further preclinical and clinical testing of this candidate vaccine.
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Affiliation(s)
- Sawsan S. Alamri
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia,Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid A. Alluhaybi
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia,Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rowa Y. Alhabbab
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia,Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammad Basabrain
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdullah Algaissi
- Department of Medical Laboratories Technology, College of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia,Medical Research Center, Jazan University, Jazan, Saudi Arabia
| | - Sarah Almahboub
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia,SaudiVax Ltd., Thuwal, Saudi Arabia
| | - Mohamed A. Alfaleh
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia,Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Turki S. Abujamel
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia,Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Wesam H. Abdulaal
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - M-Zaki ElAssouli
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Rahaf H. Alharbi
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mazen Hassanain
- SaudiVax Ltd., Thuwal, Saudi Arabia,Department of Surgery, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Anwar M. Hashem
- Vaccines and Immunotherapy Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi Arabia,Department of Medical Microbiology and Parasitology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,*Correspondence: Anwar M. Hashem,
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8
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Polat C, Ergunay K. Insights into the virologic and immunologic features of SARS-COV-2. World J Clin Cases 2021; 9:5007-5018. [PMID: 34307551 PMCID: PMC8283606 DOI: 10.12998/wjcc.v9.i19.5007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
The host immunity is crucial in determining the clinical course and prognosis of coronavirus disease 2019, where some systemic and severe manifestations are associated with excessive or suboptimal responses. Several antigenic epitopes in spike, nucleocapsid and membrane proteins of severe acute respiratory syndrome coronavirus 2 are targeted by the immune system, and a robust response with innate and adaptive components develops in infected individuals. High titer neutralizing antibodies and a balanced T cell response appears to constitute the optimal immune response to severe acute respiratory syndrome coronavirus 2, where innate and mucosal defenses also contribute significantly. Following exposure, immunological memory seems to develop and be maintained for substantial periods. Here, we provide an overview of the main aspects in antiviral immunity involving innate and adaptive responses with insights into virus structure, individual variations pertaining to disease severity as well as long-term protective immunity expected to be attained by vaccination.
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Affiliation(s)
- Ceylan Polat
- Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey
| | - Koray Ergunay
- Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey
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9
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Yaseen MO, Jamshaid H, Saif A, Hussain T. Immunomodulatory role and potential utility of various nutrients and dietary components in SARS-CoV-2 infection. INT J VITAM NUTR RES 2021; 92:35-48. [PMID: 34100300 DOI: 10.1024/0300-9831/a000715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recently, the outbreak of severe acute respiratory syndrome cornoavirus-2 (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19), has become a great perturbation all around the globe and has many devastating effects on every aspect of life. Apart from the oxygen therapy and extracorporeal membrane oxygenation, Remdesivir and Dexamethasone have been proven to be efficacious against COVID-19, along with various vaccine candidates and monoclonal antibody cocktail therapy for Regeneron. All of these are currently at different stages of clinical trials. People with weak immunity are more prone to a severe infection of SARS-CoV-2. Therefore, early and judicious nutritional supplementation along with pharmacological treatment and clinician collaborations are critical in restituting the current situation. Nutritional supplements help in acquiring strong immunity to prevent the progression of disease any further. Vitamin C, vitamin D, selenium, zinc and many other nutritional and dietary supplements inhibit the production of inflammatory cytokines during a viral infection and prevents several unwanted symptoms of infection. Many dietary components like citrus fruits, black elderberry, ginger, and probiotics have the ability to attack viral replication. These supplements can also tame the overriding immune system during coronavirus infection. Keeping in view these facts, nutritional and dietary supplements can be used along with other management modalities. These nutritional and dietary supplements are potential candidates to curb the convulsive unfolding of novel COVID-19, in combination with other standard treatment protocols. In this review, various search engines were used to exploit available literature in order to provide a comprehensive review on nutritional and dietary supplements with respect to the viral infections. It will also provide a brief overview on some of the clinical trials that are in progress to assess the role of nutritional supplements, either alone or in combination with other pharmacological drugs, in fight against COVID-19.
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Affiliation(s)
- Muhammad Osama Yaseen
- Institute of Pharmaceutical Sciences, University of Veterinary & Animal Sciences, Lahore, Pakistan
| | - Humzah Jamshaid
- Institute of Pharmaceutical Sciences, University of Veterinary & Animal Sciences, Lahore, Pakistan.,Department of Pharmacy, Quaid-e-Azam University, Islamabad, Pakistan
| | - Arifa Saif
- Institute of Pharmaceutical Sciences, University of Veterinary & Animal Sciences, Lahore, Pakistan
| | - Talib Hussain
- Institute of Pharmaceutical Sciences, University of Veterinary & Animal Sciences, Lahore, Pakistan
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10
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Kandeel M, Yamamoto M, Park BK, Al-Taher A, Watanabe A, Gohda J, Kawaguchi Y, Oh-Hashi K, Kwon HJ, Inoue JI. Discovery of New Potent anti-MERS CoV Fusion Inhibitors. Front Pharmacol 2021; 12:685161. [PMID: 34149429 PMCID: PMC8206564 DOI: 10.3389/fphar.2021.685161] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022] Open
Abstract
Middle East respiratory syndrome coronavirus (MERS-CoV), capable of zoonotic transmission, has been associated with emerging viral pneumonia in humans. In this study, a set of highly potent peptides were designed to prevent MERS-CoV fusion through competition with heptad repeat domain 2 (HR2) at its HR1 binding site. We designed eleven peptides with stronger estimated HR1 binding affinities than the wild-type peptide to prevent viral fusion with the cell membrane. Eight peptides showed strong inhibition of spike-mediated MERS-CoV cell-cell fusion with IC50 values in the nanomolar range (0.25–2.3 µM). Peptides #4–6 inhibited 95–98.3% of MERS-CoV plaque formation. Notably, peptide four showed strong inhibition of MERS-CoV plaques formation with EC50 = 0.302 µM. All peptides demonstrated safe profiles without cytotoxicity up to a concentration of 10 μM, and this cellular safety, combined with their anti-MERS-CoV antiviral activity, indicate all peptides can be regarded as potential promising antiviral agents.
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Affiliation(s)
- Mahmoud Kandeel
- Department of Biomedical Sciences, College of Veterinary Medicine, King Faisal University, Al-Ahsa, Saudi Arabia.,Department of Pharmacology, Faculty of Veterinary Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Mizuki Yamamoto
- Research Center for Asian Infectious Diseases, Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,Division of Cellular and Molecular Biology, Department of Cancer Biology, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Byoung Kwon Park
- Department of Microbiology, Hallym University College of Medicine, Chuncheon, South Korea
| | - Abdulla Al-Taher
- Department of Biomedical Sciences, College of Veterinary Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aya Watanabe
- Division of Cellular and Molecular Biology, Department of Cancer Biology, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Jin Gohda
- Research Center for Asian Infectious Diseases, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Yasushi Kawaguchi
- Research Center for Asian Infectious Diseases, Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,Division of Molecular Virology, Department of Microbiology and Immunology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kentaro Oh-Hashi
- Department of Chemistry and Biomolecular Science, Faculty of Engineering, Gifu University, Gifu, Japan
| | - Hyung-Joo Kwon
- Department of Microbiology, Hallym University College of Medicine, Chuncheon, South Korea
| | - Jun-Ichiro Inoue
- Division of Cellular and Molecular Biology, Department of Cancer Biology, Institute of Medical Science, University of Tokyo, Tokyo, Japan.,Senior Professor Office, The University of Tokyo, Tokyo, Japan
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11
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Chung MK, Zidar DA, Bristow MR, Cameron SJ, Chan T, Harding CV, Kwon DH, Singh T, Tilton JC, Tsai EJ, Tucker NR, Barnard J, Loscalzo J. COVID-19 and Cardiovascular Disease: From Bench to Bedside. Circ Res 2021; 128:1214-1236. [PMID: 33856918 PMCID: PMC8048382 DOI: 10.1161/circresaha.121.317997] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A pandemic of historic impact, coronavirus disease 2019 (COVID-19) has potential consequences on the cardiovascular health of millions of people who survive infection worldwide. Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), the etiologic agent of COVID-19, can infect the heart, vascular tissues, and circulating cells through ACE2 (angiotensin-converting enzyme 2), the host cell receptor for the viral spike protein. Acute cardiac injury is a common extrapulmonary manifestation of COVID-19 with potential chronic consequences. This update provides a review of the clinical manifestations of cardiovascular involvement, potential direct SARS-CoV-2 and indirect immune response mechanisms impacting the cardiovascular system, and implications for the management of patients after recovery from acute COVID-19 infection.
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Affiliation(s)
- Mina K. Chung
- Cleveland Clinic (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Cleveland Clinic Lerner College of Medicine (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
| | - David A. Zidar
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
- Louis Stokes Cleveland Veterans Affairs Medical Center, OH (D.A.Z.)
| | | | - Scott J. Cameron
- Cleveland Clinic (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Cleveland Clinic Lerner College of Medicine (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
| | - Timothy Chan
- Cleveland Clinic (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Cleveland Clinic Lerner College of Medicine (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
| | - Clifford V. Harding
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
| | - Deborah H. Kwon
- Cleveland Clinic (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Cleveland Clinic Lerner College of Medicine (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
| | - Tamanna Singh
- Cleveland Clinic (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Cleveland Clinic Lerner College of Medicine (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
| | - John C. Tilton
- Case Western Reserve University School of Medicine (M.K.C., D.A.Z., S.J.C., T.C., C.V.H., D.H.K., T.S., J.C.T.), OH
| | - Emily J. Tsai
- Columbia University Vagelos College of Physicians and Surgeons, New York (E.J.T.)
| | - Nathan R. Tucker
- Masonic Medical Research Institute, Utica, NY (N.R.T.)
- Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Boston, MA (N.R.T.)
| | - John Barnard
- Cleveland Clinic (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
- Cleveland Clinic Lerner College of Medicine (M.K.C., S.J.C., T.C., D.H.K., T.S., J.B.), OH
| | - Joseph Loscalzo
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (J.L.)
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12
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Lagunas-Rangel FA, Chávez-Valencia V. What do we know about the antibody responses to SARS-CoV-2? Immunobiology 2021; 226:152054. [PMID: 33524881 PMCID: PMC7826124 DOI: 10.1016/j.imbio.2021.152054] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/01/2020] [Accepted: 01/11/2021] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide causing a pandemic with millions of infected people and deaths. Currently, the scientific community is working hard to develop a specific vaccine or treatment. However, since antibody production is an important part of the adaptive immune response, to develop vaccines and therapies, we must understand the antibody response to SARS-CoV-2 infection. In this work, we summarize the most important findings of antibody-mediated immunity against SARS-CoV-2 and highlight its role in the efficient use of plasma from convalescent patients and the direct application of antibodies as treatment.
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Affiliation(s)
- Francisco Alejandro Lagunas-Rangel
- Department of Genetics and Molecular Biology, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV), Mexico City, Mexico.
| | - Venice Chávez-Valencia
- Department of Nephrology, Hospital General Regional Hospital No. 1, Instituto Mexicano del Seguro Social, Morelia, Michoacán, Mexico
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