Issue 12/2016 I I Issue 12/2016 Issue 12/2016 II

Editor-in-Chief EDITOR’S FOREWORD Hwong Yi Ling

The & Immunology Edition elcome to the 12th issue of the Scientific Malaysian magazine! It’s been six years Editors Wsince we inaugurated our very first issue, and more than a year since I took over Adaikalavan Ramasamy, PhD the baton of Editor in Chief. What a journey it has been. For the past 11 issues we have Andrew Chan, PhD kept our format of curating a selection of articles on a variety of topics, but it is now time Beatrice Chin Hui Tze to change. From this issue onward, we are changing the magazine format to focus on one Jaa Yien New, PhD theme per issue. This issue is our first experiment with this new format, and the theme is a Juliana Ariffin, PhD CONTENTS Kok Onn Kwong subject that has been much debated and is close to my heart - Immunology and . JUNE 2016 ISSUE NUMBER 12 Lee Khai Ern, PhD Valerie Soo, PhD To kick off our first ever theme-based issue, we are also running a writing competition. Our Lee Hooi Ling, PhD editors have combed through the submissions we received and shortlisted 10 articles as Vaccines: An Immunological Revolution finalists for the competition. They have all been included in this issue. We will be inviting Featuring: 1 By Juliana Ariffin you, our dear readers, to vote and help us decide the winner. So do keep an eye out for Designer The Top 10 Finalists your favourite article. Xinhui Yap Viruses as a Cure for Cancer? of SciMy’s Writing 8 By Suet Lin Chia Almost every article in this issue has been written by an expert or researcher trained in Illustration the field of immunology and vaccines. To start off, we have Juliana Ariffin, one of our Alle Chun Kong Yink Heay Superhero regular writers and a postdoctoral research fellow in Harvard Medical School, offering Competition Mohd. Arshad Yusoff By Candice Lim an overview on the history of vaccines and the immunological revolution that they have Suet Lin Chia 12 brought on (pg 1). Next writes about cancer virotherapy, a concept of using SCIENTIFIC MALAYSIAN EDITOR’S FOREWORD Childhood Vaccine Controversies: the virus to kill cancer cells, and how we can turn virus from a foe to a friend in the fight against MAGAZINE is published in a Myths, the Facts and the Uncertainties cancer (pg 8). For lovers of short fiction stories, don’t miss the creative piece by Candice web format (http://magazine. II 15 By Adli Ali Lim, a science fiction writer. Find out how her young protagonist came to realise she is a scientificmalaysian.com) and superhero in the making (pg 12). in a downloadable digital A ‘Trp’ to the Land of Kyns magazine format (PDF). 81 By Felicita Fedelis Jusof What are the vaccine-related controversies that have stirred ongoing discussions among Our digital magazines are SciMy Ask Me 21 the public? What does science say? Adli Ali gives a verdict for each of these controversies distributed to Malaysian societies around the world. Snake Antivenoms: Science, Values & and explains the reasons behind them (pg 15). Next, Felicita Fedelis Jusof takes us on a Anything (AMA): The Scientific Malaysian ‘trip’ to the land of Kyns and describes the mechanism behind the kynurenine pathway and Challenges Magazine is published bi- Betty Kim Lee Sim 32 By Tan Choo Hock how it impacts a myriad of immunological processes (pg 21). ‘Feared or loved, but rarely annually and it is FREE of understood’, those are the words Tan Choo Hock, a toxinology expert, used to describe charge. The Founder of Protein The Imitation snakes. Read his piece on snake antivenoms and get an intimate view into the fascinating Potential LLC & Executive By Nur Atikah Abdullah, Charles George venom-antivenom interplay (pg 32). Following this we have another fiction piece written DISCLAIMER Vice-President at Sanaria Inc. 39 Gajim & Seti Faezah Rosli jointly by Nur Atikah Abdullah, Charles George Gajim, and Seti Faezah Rosli. What will Opinions and articles lets us in on her thoughts and a world without vaccine look like? Read on to find out (pg 39). published in Scientific experiences. Teaching Your Immune System to Fight Malaysian Magazine do Cancer Litt-Yee Hiew writes about the latest developments in a new form of cancer treatment - not necessarily reflect those of the editors/staff 43 By Litt-Yee Hiew immunotherapy and offers her views on the opportunities presented by this novel technique, and members of SciMy. especially for advanced stage cancer (pg 43). In a comprehensive article, Adaikalavan Gems All articles and original Ramasamy provides us with valuable insights into malaria the disease and the progress From Current Progress on Malaria Vaccines photos/illustrations cannot By Adaikalavan Ramasamy that has been made in developing a (pg 53). Last but not least we have a be reproduced without Our 53 piece on dengue, which has made an unwelcome comeback in our country, apparent by the prior permission from the Web The Dilemma: Route to steep increase in the number of outbreaks in recent years. Nor Ilham Ainaa elaborates on author(s) and Scientific Prevention - Are We There Yet? the development of dengue vaccines as a viable route to prevention (pg 70). Malaysian. 87 Articles 70 By Nor Ilham Ainaa Do write to us with any comments or feedback you have, or if you would like to see CONTACT DETAILS a particular theme being featured. We would love to hear from you: magazine@ Email: magazine@ scientificmalaysian.com. scientificmalaysian.com Website: http://www. scientificmalaysian.com Have a delightful read, and in the words of the wise Neil deGrasse Tyson, keep looking up. Facebook: http://facebook. Cover Illustration com/ScientificMalaysian The cover image for this issue symbolises the focus of our theme; depicting the combat against diseases Hwong Yi Ling Twitter: @ScientificMsian through the development and enlistment of vaccines and immunology. Adapted from an illustration by Editor-in-Chief Mohd Arshad; Scientific Malaysian Magazine Issue 12 (June 2016) © [email protected] 1 Issue 12/2016 Issue 12/2016 2

The World’s First Vaccine Vanquishes Smallpox; The Killer of Kings Vaccines: pproximately 3,000 years ago in Within the next few days, a bumpy rash ancient Egypt, there lived a young appeared all over his face and body, and Apharaoh by the name of Ramses V. sores developed in his mouth, throat and nose. An immunological Not much is known about his reign, except that These rashes then swelled further and leaked almost 4 years after he was anointed as the infectious pus. ‘living god’ of Egypt, Ramses V probably felt Revolution unusually lethargic and feverish. Finally in 1157 B.C., approximately two weeks after he fell sick, Ramses V died, leaving only his By Juliana Ariffin He might also have thrown up a few times, scarred and mummified remains as his legacy. had a sore throat or a bad headache. Initially, These would be discovered in 1910 A.D., and these symptoms might have been attributed would become the earliest physical evidence to a minor malady, such as the flu or stress. of smallpox [2], one of the deadliest, and now However, these symptoms were just a prelude. extinct, diseases to have plagued humankind. Did you know that if you went back in time, most of you would be immune to some of the most devastating diseases that have ravaged humankind in the past? We owe Of variolation and vaccines this invisible armour that we possess to the Unfortunately for Ramses V, no reliable The fight against smallpox, and thus the hard work and sacrifice of our predecessors way to guard against smallpox existed during discovery of vaccines, began in 430 B.C. his time. In fact, since 10,000 B.C., humans when the Athenian, Thucydides, observed who discovered… you guessed it, vaccines! have been vulnerable to smallpox epidemics that survivors of smallpox became immune that trailed the pattern of human migration, to it. In 910 A.D., the Persian alchemist- resulting in a marked impact on human physician-philosopher, Abu Bakr Muhammad history—smallpox is known to have been Bin Zakariya Ar-Razi (Rhazes), also noted the more influential in bringing down the Aztec immunity of survivors and person-to-to-person and Incan empires than the invading Spanish transmission of smallpox, leading him to Conquistadors [3]. By the end of the 18th propose the first theory of acquired immunity century, smallpox had killed five European [3, 4]. IMMUNOLOGY kings, and by the 20th century 300-500 million FIGHTS BACK people worldwide had died from smallpox, a Thucydides and Rhazes were not alone in number far exceeding the combined fatalities their observations. By 600 A.D., physicians in from the two world wars [3]. China were grinding up dried smallpox scabs 3 Issue 12/2016 Issue 12/2016 4

with musk to inoculate the noses of healthy In 1795, observed that How vaccines work people, while people in India wore shirts milkmaids who had contracted cowpox were from infected patients and slept alongside immune to smallpox. He experimented using ince Edward Jenner’s discovery, This system of speedy recognition and the smallpox victims [3, 5]. In Africa and the Middle the pus from a cowpox pustule on a milkmaid, vaccines have been developed for launching of a specific defence is termed East, scrapings from smallpox pustules from a Sarah Nelmes, to inoculate scratches on the Smany other diseases including polio, adaptive immunity, and is what enables the mildly infected individual were applied onto a arm of an 8-year-old boy, James Phipps. chicken pox, hepatitis B, human papillomavirus body to destroy invading microorganisms scratch or a vein of a healthy person. These Luckily for James, he developed cowpox, but (HPV) and influenza. before they enter cells, or to destroy infected methods of transmitting smallpox are called like the milkmaids, was immune to smallpox. cells before the microorganism can multiply variolation, and were conducted with the hope Jenner then developed the world’s first vaccine These vaccines work by introducing an to huge numbers within the body. When that a minor with smallpox would using cow serum containing the cowpox virus agent (Infobox 1) from a disease-causing developing a vaccine, the biggest concern is occur, stimulating the immune response and [7]. This method of preventing smallpox was microorganism that is recognised by the immune how best to induce an immune reaction while conferring immunity against the disease [3, 5]. strongly supported by the then U.S President, system as a threat. This agent stimulates an keeping the risk of developing the disease low. Thomas Jefferson, and Napoleon Bonaparte, immune reaction that persists for years in the Variolation was practised for hundreds who had his entire army vaccinated in form of ‘immunological memory’, enabling a While protects against a disease, of years although it was not a foolproof 1805 and ordered all French civilians to be quicker and more effective immune response it doesn’t always confer lasting protection. method, due to variations in the amount of vaccinated a year later [8]. Over the next few upon future encounters with the microorganism. Just as normal memories fade, immunological virus transmitted, and the fact that inoculated centuries, immunity against smallpox became individuals could still transmit the disease. Still, widespread, resulting in global eradication of it saved the lives of many, including Catherine the disease in 1980 [9]. the Great and her son [5], and was used by George Washington to safeguard the American army during the War of Independence against Great Britain [6]. INFOBOX 1 Types of vaccines and the diseases they protect against [18, 19] “physicians in China were grinding up Dried smallpox scabs ...to inoculate the noses of healthy people” 5 Issue 12/2016 Issue 12/2016 6

memory can also decline, resulting in lost to regain immunity. Example of vaccines that Herd Immunity (image credit to Bioninja [20]) immunity years after the initial vaccination. normally require follow-up booster shots FIG. 1 This can be detected by measuring antibody include the oral (OPV) which levels agains the vaccinated agent. In cases persists for only 6 months and tetanus, which where immunity has declined, administration requires a booster shot every 10 years. of a ‘booster’ shot, or an extra administration of a vaccine following the earlier dose, helps

Herd immunity and pox parties

hildren are usually vaccinated as soon if conferred lasting protection, as their immune system is sufficiently this would not be such a major concern for Cdeveloped, and many countries have everyone. Indeed, the biggest threat would be a schedule of recommended vaccinations. unvaccinated children succumbing to severe However, the large number of injections for disease and being at risk of fatality or deformity. vaccinations and booster shots, as well as the fear of side effects often leads to problems in However, as mentioned above, vaccinations compliance with the schedule. do not confer lasting protection. Also, individuals who are too young, too old, pregnant, or One of the biggest hindrances for vaccination immunocompromised are unable to receive was the fraudulent claim by Andrew Wakefield, vaccinations. These individuals are at high risk a former British surgeon and medical of contracting disease if they come in contact researcher who published a paper that with an infected individual. described a link between the measles, mumps and rubella (MMR) vaccine, and the occurrence Normally, the number of vaccinated About the author: of autism and bowel disease [10]. Although his individuals is high enough that it confers what is research was not reproducible, was shown to termed ‘herd immunity’ (Fig. 1) to a population, be financially motivated and was also revealed where the incidence of contracting the disease Juliana Ariffin is a postdoctoral fellow researching to be conducted without ethical approval [10], is so low that even unvaccinated individuals liver inflammation at Beth Israel Deaconess, Medical Center, mass media disseminated his findings reporting will be protected. However, if the number of a link between vaccination and autism. As a unvaccinated individuals increases, such as an Harvard Medical School. Prior to this, she studied human result, many parents have chosen to ‘protect’ increase in immunocompromised individuals or immune responses at The Institute for Molecular Biosciences, their children from autism by not allowing them when children are intentionally not vaccinated The University of Queensland. In her spare time she reads to be vaccinated. (even if they do not attend pox parties), herd and writes fiction, dabbles in photography and considers immunity is no longer effective and the genetically engineering a zombie propagating virus to Instead, some parents have resorted to population becomes at risk of a disease repopulate the earth. holding pox parties where healthy children are epidemic [11]. exposed to a child infected with a disease such as chickenpox, measles, or rubella. Similarly Find out more about Juliana Ariffin by visiting her Scientific to variolation, this hopefully allows for an Malaysian profile: infection and acquisition of natural immunity. If the majority of the public were vaccinated, and http://www.scientificmalaysian.com/members/julianna/ 7 Issue 12/2016 Issue 12/2016 8 REFERENCES 1) Ramesses V, Wikipedia entry. (https:// 13) Centers for Disease Control and Prevention, en.wikipedia.org/wiki/Ramesses_V) Emergency Preparedness and Response, Smallpox. (http://www.bt.cdc.gov/agent/ 2) Erik Hornung. (1997). The Pharaoh, p.292 smallpox/vaccination/faq.asp). in The Egyptians (ed.) Sergio Donadoni and Robert Bianchi, University of Chicago Press. 14) Penny Sarchet. (2016). Use vaccines as a weapon against antibiotic-resistant bacteria, 3) Epidemics of the Past, Smallpox: 12,000 Newscientist. (https://www.newscientist.com/ Years of Terror. (http://www.infoplease.com/ article/2077157-use-vaccines-as-a-weapon- cig/dangerous-diseases-epidemics/smallpox- against-antibiotic-resistant-bacteria/) Viruses as a Cure for Cancer? 12000-years-terror.html) 15) Michael Brooks. (2016). Booster shots: By Suet Lin Chia 4) SC Ashtiyani, A Amoozandeh. (2010). the accidental advantages of vaccines, Rhazes Diagnostic Differentiation of Smallpox Newscientist. (https://www.newscientist.com/ and Measles, Iranian Red Crescent Medical article/dn24027-booster-shots-the-accidental- Journal. (http://ircmj.com/291.fulltext) advantages-of-vaccines/)

5) Variolation, Wikipedia entry (https:// 16) Lindsey et al., (2016). Assessment of the en.wikipedia.org/wiki/Variolation) Safety and Immunogenicity of 2 Novel Vaccine Platforms for HIV-1 Prevention: A Randomised 6) Benjamin A. Drew. (2015). George Washington Trial, Annals of Internal Medicine. (http://annals. At a Glance: and Smallpox, A Revolutionary Hero and org/article.aspx?articleid=2484873) Public Health Activist, JAMA Dermatology. Cancer has been haunting the human population for centuries. Despite the (http://archderm.jamanetwork.com/article. 17) Abhishek et al., (2016). Dendritic cell availability of various current treatments, the number of cancer patients is aspx?articleID=2169316) vaccines based on immunogenic cell death on the rise. This article discusses an alternative treatment for cancer – cancer elicit danger signals and T cell-driven rejection virotherapy, a concept of using virus to kill cancer cells. It has been the subject 7) Stefan Riedel. (2005). Edward Jenner and of high-grade glioma, Science Translational the history of smallpox and vaccination, Proc Medicine. (http://stm.sciencemag.org/ of investigation for decades but has only recently been approved by the US (Bayl Univ Med Cent). (http://www.ncbi.nlm.nih. content/8/328/328ra27) Food and Drug Administration (FDA) as a therapeutic agent for cancer. A gov/pmc/articles/PMC1200696/) brief description of the history of virotherapy, how the virus kill the cancer 18) Vaccine, Wikipedia entry. (https:// cells, the benefits of this treatment as well as the outcome are discussed. 8) Sheryl Persson. (2010). Smallpox, Syphilis en.wikipedia.org/wiki/Vaccine) and Salvation: Medical Breakthroughs that Changed the World. 19) World Health Organisation, Vaccine Safety Basics, Types of Vaccine. (http://vaccine- 9) World Health Organisation, Smallpox. (http:// safety-training.org/types-of-vaccine.html) www.who.int/csr/disease/smallpox/en/) 20) Bioninja, Vaccination (http://ib.bioninja.com. , (or spread) to other organs of cancers detected even in 10) Andrew Wakefield, Wikipedia entry. https://( au/higher-level/topic-11-animal-physiology/111- In today’s society cancer is no longer a foreign and are beyond curability with early stages of the disease en.wikipedia.org/wiki/Andrew_Wakefield) antibody-production-and/vaccination.html) word. The chances that we current technologies. In cases would occur again, with a much know someone who has been of early detection, surgical higher rate of recurrence in 11) Vaccines.gov, Community Immunity. (http:// procedures can be performed to late stage cancers. Recurrence www.vaccines.gov/basics/protection/) diagnosed with or died from cancer are on the rise. In remove the cancer, followed by arises from the “escape” of 2012 alone, the World Health chemotherapy and radiotherapy some cancer cells from surgery 12) Centers for Disease Control and Prevention, to kill any remaining “escaped” or chemotherapy which Vaccines and Immunisations (http://www.cdc. Organisation (WHO) reported cells. These treatments have subsequently develop resistance gov/vaccines/vac-gen/whatifstop.htm). 32.6 million people living with cancer, 14.1 million new cases become so commonplace that towards chemotherapy drugs. and 8.2 million deaths from they are considered obligatory And when they come back, they cancer. Most fatalities result for any cancer treatment come back with a vengeance. from late diagnosis or treatment. regimen. Less recognised is These cancer cells continue to In many of these cases, the that, after surgical excision grow, forming a more aggressive cancer cells have metastasised and chemotherapy, 40-60% cancerous cell population that 9 Issue 12/2016 Issue 12/2016 10 current treatments cannot kill. the host. For example, hepatitis known as “oncolysis” (“onco”: Clearly, we need more effective viruses infect liver cells but not cancer; “lysis”: killing by anti-cancer therapies. brain cells. Similarly, a virus that disrupting the cell membrane). infects cancer cells will not infect This phenomenon was first normal cells. Even if normal reported in the early 19th cells are infected by accident, century in a cancer patient Progress in science defence proteins present in infected with the influenza virus. Curiously, the cancer and technology has shrank after infection with made it possible to engineer virus, are responsible addition, as cancer cells are approximately 15-30 patients the virus. Although scientists viruses to kill cancer cells in for animal diseases. Whilst a burst open and killed, the body’s to determine the safe dosage, did not fully understand the patients. Viruses are very number of viruses, including immune cells are attracted route of administration of the phenomenon, they suggested “Oncolysis” Newcastle disease virus and to the “war zone” to clear the treatment and effects of the small particles, invisible Onco: that the virus might have even under a normal reoviruses, possess a natural destroyed cells. This, in turn, new treatment on the human contributed to the remission. microscope. In order to Cancer ability to selectively kill cancer educates our immune system body; phase II involves less than In the years that followed, replicate, viruses must cells, others can be genetically to recognise distinct “traits” or 100 patients to determine the substantial research focused infect specific cells in the Lysis: modified to kill tumour cells but cancer antigens, which act like effectiveness of the treatment on identifying existing viruses host (such as plants, animals spare normal cells. a “”, and start for various cancers and also the Killing by disrupting the cell with similar cancer-killing or bacteria). Infection attacking remaining cancer cells treatment’s effect on human properties. Surprisingly, many occurs via proteins on the membrane including those at a distant site body; phase III involves hundreds viruses were found to be surface of the virus that act that display these antigens on to thousands of patients to very promising in destroying But how do viruses as a “key” that inserts into a their surface. As the cancer cell compare the effectiveness of these cells, but not in their cancer cells. Some viruses, kill cancer cells? Generally, “lock”, represented by receptor population is killed, the oncolytic the new treatment compared to cancerous counterparts, will such as coxsackieviruses, cancer cells were once normal proteins on cell surface. The viruses run out of host cells to the current standard treatment. fight off the virus and prevent its reoviruses, herpes simplex cells with finite lifespans, interaction between the two grow in and are cleared by the Many oncolytic viruses are replication. viruses and adenoviruses, are dying through a process called proteins helps the virus to enter body’s immune system. currently in phases responsible for the flu, cold programmed cell death. Cancer the cell and begin to replicate. I, II or III. OncoVEX (herpes sores, and gastrointestinal cells, however, may acquire The key-and-lock system is so simplex virus) and Reolysin® diseases in humans. Others, mutations in genes responsible specific that viruses will only Viruses kill cancer (reovirus) are examples of like Newcastle disease virus and for cell death. This prevents Despite numerous recognise specific cell types in cells through a process oncolytic viruses currently being cancer cells from undergoing studied in phase III clinical trials. normal programmed cell death studies indicating that oncolytic viruses are relatively Once the therapeutic benefit has and allows them to continue been demonstrated, they can be growing unchecked. This safe for use in humans (see for example, [1]), the general approved by the Food and Drug uncontrolled growth eventually Administration (FDA) for use as leads to a lump of cancer cells public remains sceptical. Such scepticism is the very reason cancer treatment in hospitals. In and the creation of a favourable fact, 2015 was a historic year for “habitat” for oncolytic viruses, that therapeutic agents undergo many stages of preclinical cancer virotherapy. IMLYGIC™ which exploit the immortal (talimogene laherparepvec), properties of cancer cells as trials on animals, followed by very closely monitored a genetically modified herpes virus production factories. As simplex virus, was the first the viruses mature, they burst clinical trials in humans. Clinical trials commonly consist of oncolytic virus to be licenced open the cell and spread to by the FDA for the treatment surrounding cancer cells. In three phases: phase I involves

“Despite numerous studies indicating that oncolytic viruses are relatively safe for use in humans... the general public remains sceptical”

Illustration by Kong Yink Heay 11 Issue 12/2016 Issue 12/2016 12 of melanoma. In addition, flu-like symptoms) compared part, why only a few countries in Oncorine (adenovirus) has also to those from chemotherapy the world currently provide this been approved in China for use and radiotherapy [1,5]. Despite treatment. Nevertheless, with in cancer treatments. promising results in clinical trials, international teams of scientists however, virotherapy does have currently working on genetically its limitations. Though these modifying oncolytic viruses So far, patients’ viruses are used therapeutically, to improve their safety and they are still recognised as efficacy, and many more viruses SUPERHERO outcomes have been very promising, and clinical foreign particles or “antigens” under investigation with the ...By Candice Lim Illustrations by Alle Chun successes were reproducible to our body. This alerts the hope of isolating more potent [2,3]. Solid cancer masses in body’s immune response to variants, the future is bright for stage IV (final stage of cancer) detect and eliminate the viruses virotherapy. One day, we hope patients have been shown to from the body. In addition, the to be able to treat cancer like a “Mommy, Hi, I’m Leila! shrink or at least cease growing administration of viral therapies common flu or fever with widely [4]. Importantly, these therapies requires trained professionals available oncolytic virus pills I don’t wanna take Today is the day to get may also give patients a better and close monitoring of the and eliminate the public fear quality of life; virus treatments patients during treatment. associated with cancer. my flu shot, but I don’t are associated with much fewer These requirements pose major the shot,” want to, because it’s and milder side-effects (i.e. obstacles and explain, at least in gonna hurt! Leila whimpered the little girl in my clinic this morning. About The Author: She was dressed all in pink and didn’t look and it’s killed many people...” She paused, then Suet Lin Chia is a senior lecturer at the Department of Microbiology in the Faculty more than five years old. continued. “Daddy’s one of them.” of Biotechnology and Biomolecular Sciences at the Universiti Putra Malaysia. He “Please be a good girl, Leila. It’s not gonna I nodded and swallowed the lump in my throat. is currently a postdoctoral research fellow working on oncolytic virotherapy in the hurt,” coaxed her mother. She looked tired and The virus was strong and had claimed more laboratory of Professor Len Seymour at the University of Oxford. The author has also had two black circles under her baggy eyes. Like lives than scientists had predicted it would. The collaborated extensively with Professor Datin Paduka Khatijah Yusoff in the field of the rest of the patients milling in the waiting nation was in a panic. When the Food and Drug room, she had come with her daughter to get Administration (FDA) gave the green light for virotherapy. Dr. Chia aims to contribute to the development of cancer therapeutics her flu shot. the new vaccine, everybody started to queue up and welcomes collaborations with researchers with the same goal. The author can at the nearest clinics to get their shots. “Do you be contacted at [email protected]. To find out more about the author, visit his know what that means?” Scientific Malaysian profile at: “It means we’re gonna die.” http://www.scientificmalaysian.com/members/eddiecsl324/ “No, Leila.” I took her hands and smiled at her. “You’re not going to die.”

References: “Then… then, why do we have to take the 4. Carroll J (2013) Amgen trumpets T-Vec oncolytic virus results from Ph III melanoma study. Chicago, shots?” 1. Zeh HJ, Downs-Canner S, McCart JA, Guo ZS, Rao IL: FierceBiotech; 2013 [cited 2016 Feb 11]. Available I sat down next to Leila and took her hand. UN, Ramalingam L, Thorne SH, Jones HL, Kalinski P, from: http://www.fiercebiotech.com/story/amgen- She looked at me with her two big eyes. Wieckowski E, O’Malley ME, Daneshmand M, Hu K, Bell trumpets-t-vec-oncolytic-virus-results-phiii-melanoma- JC, Hwang TH, Moon A, Breitbach CJ, Kirn DH, Bartlett study/2013-06-01. “Hello, my name’s Doctor Hershey. What’s “We’re going DL (2015) First-in-man study of Western Reserve strain oncolytic vaccinia virus: safety, systemic spread, and your name?” 5. Chen NG, Szalay AA (2011) Oncolytic virotherapy of to make you a antitumor activity. Mol Ther 23(1): 202–214. Cancer in: Miner BR (ed.) Cancer management in Man: “Leila.” She took my hand hesitantly and Chemotherapy, Biological Therapy, Hyperthermia and 2. Russell SJ, Peng KW, Bell JC (2012) Oncolytic quickly let go. Superhero.” Supporting Measures. Springer Science+Business Media virotherapy. Nat Biotechnol 30(7): 658–670. “Nice to meet you, Leila. Now, can you tell me B.V. pp.295-316. what’s happening?” 3. Chiocca EA, Rabkin SD (2014) Oncolytic viruses and their application to . Cancer Leila looked around her for a while, then Doctor Hershey Immunol Res 2(4): 295–300. stared at her feet. “There’s a new virus out there 13 Issue 12/2016 Issue 12/2016 14

“A superhero?” Leila’s eyes lit up as she Your body’s strong enough to withstand the “I can’t believe it. Superheroes are real!” Leila Science can make them superheroes. They don’t grinned, baring her two missing front teeth. It’s vaccine. But, what about the newborns, pregnant smiled brightly at her mother. “I’ve always know that day came a long time ago.” Removing been a while since I saw a smile, especially from women, and those with life-threatening thought they were only in the movies.” the syringe from the metal tray and pushing the a child. illnesses?” air out, I beamed at the little girl. Leila and her “They are. They just fight a different kind mother looked so much happier and confident I nodded. “Yes, the shot will give you the of bad guy. Many people anticipate the day than when they first came in. superpower to protect yourself and others who can’t have their own injection against the virus.”

“But.” Leila turned to look at Mommy. “Mommy good viruses bad viruses told me the shot contains viruses. I don’t wanna “So, Leila, are you ready to receive have viruses in my body.” your superpower?” “Yes, they are, but do you know what they do?” “They cannot be vaccinated?” Leila frowned. Leila shook her head. I shook my head. “Their bodies cannot resist “These viruses are inactivated, meaning they even the inactivated viruses. They’ll have to cannot make copies of themselves or cause depend on the people around them to be their harm to your body. They’re safe. There’s nothing human shield. If no one has the immunity, the to worry about. Your body will still see them flu can spread around and get to them easily. as a threat and when it does, it will produce But when most people get their shots, there’s antibodies to attack them. Then your body will little chance for an outbreak. In this way, the remember the virus. If you happen to come into vulnerable ones are protected from the disease. contact with the flu, your body will immediately This is called ‘herd’ or ‘community immunity’ [3- Leila recognise the same virus and produce the 4].” antibodies to fight them. This is called ‘active immunity’ [1-2].” Leila bit her lip and bent her head. “It’s gonna hurt a lot, right?” ABOUT THE AUTHOR Candice Lim Wan Chi is a science writer by day and a science fiction and “Well, this is the test you have to go through fantasy (SFF) novelist by night. Graduated with a biotech degree, her research to become a true superhero. Do you think you’re interests lie in genetics, tissue culture, transgenesis, and of course cyborgs, brave enough to be a superhero?” androids, blasters, and spaceships. She’s working to publish her SFF trilogies Leila stared at me for a couple of seconds and “Outbreak” and “Hell Break” under pseudonym James Levin. She hopes to nodded confidently. “Yes, I am. I can do this!” pursue an entrepreneurial venture in science.

POWER I turned to the mother as she ran her hand over Find out more about Candice by visiting her profile at: her daughter’s hair. “You’re so lucky, ma’am. You http://www.scientificmalaysian.com/members/candistic/ have a brave daughter. I’m sure she’s going to be a great superhero.” References “Cool!” exclaimed the little girl. “That means “Thank you so much, Doctor. Leila was so I’m invincible!” worried when I told her we’re going to get our 1)Burton, D. R. (2002). Antibodies, viruses and vaccines. Nature Re- flu shots,” said Leila’s mother thankfully. views Immunology, 2(9), 706-713. “Against the flu virus, yes.” 2)Pulendran, B., & Ahmed, R. (2011). Immunological mechanisms of “But, how can I protect others?” “Don’t mention it, ma’am. That’s our job.” vaccination. Nature Immunology, 12(6), 509–517.

“Look, Leila. You’re a strong and healthy girl. 3)Fine, P., Eames, K., & Heymann, D. L. (2011). “Herd immunity”: A rough guide. Clinical Infectious Diseases, 52(7), 911-916.

4) Valleron, A. J. (2012). Can the modeling of herd immunity help design influenza policy?. Preventive Medicine, 55(1), 78- 79. 15 Issue 12/2016 Issue 12/2016 16 Childhood CONTROVERSY 1: Vaccines cause autism

Verdict: MYTH

Vaccine This “myth” was based on an article published in 1998 in The Lancet, written by Andrew Wakefield, a British surgeon, suggesting that the measles, mumps and rubella (MMR) vaccine increased autism incidences among British children [1]. This “infamous” article and his claim on Controversies: the causal-relationship between that ended up being discredited created a widespread fear among the public. Up until now, none of the numerous subsequent studies conducted were able to prove Dr. Wakefield’s claim and no scientific evidence has proven any possible link between the MMR vaccine and autism [2, 3, 4]. The article was eventually deemed flawed and retracted by The Lancet based on the serious procedural errors, undisclosed financial conflicts of interest, and ethical violations [5]. This controversy will always be a major myth in the the myths, the facts vaccine world, hence, is officially referred to as the most damaging medical hoax of the century. and the uncertainties

By Adli Ali

Vaccine controversies and anti-vaccine movements are not something new. They began some 90 years ago in the early 20th century, even before the term “vaccination” was formally used. Let us now revisit what we may consider to be the 7 most scientifically relevant controversial issues relating to “vaccines” and “vaccination” and explore the facts and verdicts for each of these issues.

Figure 1: Reduction of measles cases and death upon introduction in 1968 in England and Wales (Data source: Public Health of England [17]) 17 Issue 12/2016 Issue 12/2016 18

CONTROVERSY 2: CONTROVERSY 4: Vaccines contain mercury and are Human foetuses are aborted to damaging to the body, leading to produce vaccines autism Verdict: PARTIAL FACT

Verdict: MYTH Research development and production of vaccines, especially in virus-based-vaccines, require culturing of the virus in specific human cells. The statement that human foetuses were aborted Vaccines did contain , an organic mercury-containing compound, which was used in to produce vaccine is untrue, as in the development process of vaccines, commercial-laboratory small amounts previously as antifungal preservative in some multi-doses vaccines. The amount produced human cell-line culture are being used [9]. Nonetheless, historically, these commercially used was significantly below the acceptable level considered tolerable by the World Health grown cells were harvested through intentional medically-sacrificed human fetuses, approved Organisation (WHO), and had evidently proven to be safe. Nonetheless, as a precautionary principle, and monitored strictly by ethical bodies, and a few decades ago, this was done purely for the Center for Disease Control (CDC) had directed removal of thiomersal from all childhood vaccines need of the scientific research [10, 11]. No subsequent abortion was performed thereafter for any in 1999 [6]. Concerns on Thiomersal could have been responsible for autism was disapproved other scientific purposes. The usage of these foetus cell lines is extensive, extending to many based on the fact that no causal relationship was ever documented, and despite current removal different fields of the sciences, not just vaccine research and development. of thiomersal-based vaccines, the steady increase in incidences of autism is maintained [7].

CONTROVERSY 3: Some vaccines are not Halal

Verdict: PARTIAL FACT

Some vaccines use porcine-based-enzymes in their production, creating concerns on the “halal”ness of those vaccines. However, despite the fact that these enzymes are used in some of the processes of the vaccine manufacturing, the Islamic fatwa committee has allowed the usage of these vaccines. This is based on several Islamic principles in dissecting the issue. On the “halal”ness of the vaccine product itself, the concept of the “tiny amount” of enzymes added to the huge quantity of vaccine solution produced, in line with the concept of “suci” or “pure element” in Islam. Secondly, the removal of the used enzymes in the final production is also parallel to the concept of “cleanliness and pure element” in Islam, hence making the final product as “not containing” any of the “non-halal” elements through the principle of look, smell and taste. Finally, based on the crucial need of using the vaccine in disease prevention in situations whereby we do not have other “purely halal” alternatives, Islamic scholars have ruled that the use of this vaccine may be allowed in accordance to a ruling based on the concept of “dharurah” or emergency situations. However there exist some differences of opinion on this matter, whereby the more strict Illustration scholars cannot accept this new “law” based on “ijma” or “agreements” of scholars, particularly in by Mohd Arshad relation to the “halal” concept [8]. 19 Issue 12/2016 Issue 12/2016 20

CONTROVERSY 5: CONTROVERSY 7: Natural protection is adequate Vaccination is not without side and safer, vaccination is just effects redundant Verdict: FACT

Verdict: PARTIAL FACT As with any other drugs or interventions, vaccination is, of course, not without side effects. Most of them are mild and tolerable side effects such as fever, flu-like illness, and pain and/or redness at Natural infection does provide lifelong immunity against certain . However, in the case local injection site pain. These known side effects are clearly stated in the information sheets and of most vaccine-preventable diseases, the idea that natural infection is safer and adequate is well-tolerated in many. Development of vaccines, as with most drugs, involves several phases, and dangerously untrue. Vaccine-preventable infections are proven to cause significant health safety is among the first phase requirement before the candidate vaccine even goes to the clinical problems, such as neurological side effects (or sequelae) from Hemophilus influenza meningitis trial phase. Nonetheless, there were incidences where serious and unexpected complications and birth defects from maternal rubella infection, and fatality. In some organisms, a single naturally occurred and only recognised after the wide usage of the vaccine within the population. One occurring infection may not be adequate to prevent the next infection and may lead to more example is in the case of the , Rotashield. This vaccination causes an increased severe disease, such as in the case of Dengue fever. Vaccination does not only prevent infection, incidence of intussusception among toddlers, leading to its retraction from usage soon after it but also prevents the disease associated with natural infection, i.e. cervical cancer through Human was noticed [13]. Tight surveillance is in place to monitor the safety of any drug and vaccine, Papillomavirus (HPV) vaccination and hepatitis through Hepatitis B vaccination. As many organisms as experience in different wider population might reveal new entities not discovered during the also have several serotypes, vaccination is not redundant in naturally protected individuals, as the clinical trials. vaccine may provide protection against other serotypes and enhance immune response towards the naturally protected serotype.

CONTROVERSY 6: Too many childhood vaccinations, immune system overloaded There are several other arguments, not discussed in this article, that are being exploited by the anti-vaccine movements which are based on sentiment and false-beliefs [14]. Faulty arguments that Verdict: MYTH we do not need vaccination for measles since the infection is no

longer a major problem, has led to the current measles outbreak Our immune system is just remarkable. Without us even realising it, the immune system is in several countries [15, 16]. It is important for scientists, constantly exposed and able to prevent infections competently. Giving several vaccines at the physicians and patients to know the advantages and the limitation same time is shown to be safe, immunologically effective, logistically and economically efficient. of vaccines. Vaccination has come a long way since its discovery Concerns on overloading the immune system are false and based on a non-immunological and had changed its primary role in infection prevention, to even assumption. It is crucial that protection is achieved by a certain point of time in a child’s life. This is based on the epidemiological knowledge on the prevalence and likeliness to encounter the therapeutic and disease prevention now. The new technology embedded infection. Combination vaccines also means less injections which lead to less parental anxiety and in vaccine development, using an antigenic part of the pathogen stress on the child [12]. () or the pathogen’s DNA materials (DNA vaccine) may not just come with less side effects, but possibly a more effective vaccine and also the answer to many more diseases that need to be tackled where a vaccine is yet to be developed. 21 Issue 12/2016 Issue 12/2016 22

About The Author:

Dr Adli Ali is a medical academician and clinical scientist, passionate about exploring the mysterious and fascinating world of immunology. A paediatrician at heart and by training, he also loves the science of fantastic gourmet and the art of travelling the world. Currently furthering his sub-specialisation at University of Oxford, he is ambitious and determined to develop and enhance the translational clinical and collaborative medical research in the region.

To find out more about the author, visit his Scientific Malaysian profile at http://www.scientificmalaysian.com/members/adliali/

References 1. Wakefield A, Murch S, Anthony A; et al. (1998). mental Cell Research 37: 614–636. doi:10.1016/0014- “Ileal-lymphoid-nodular hyperplasia, non-specific coli- 4827(65)90211-9 tis, and pervasive developmental disorder in children”. Lancet 351 (9103) : 637–41. 11. Jacobs, Characteristics of a human diploid cell des- ignated MRC-5 (1970). Nature 277:168:247-56 1970 2. Godlee Fiona, Smith Jane, Marcovitch Harvey. Wakefield’s article linking MMR vaccine and autism 12. Addressing Parents’ Concerns: Do Multiple Vac- was fraudulent BMJ 2011; 342 :c7452 cines Overwhelm or Weaken the Infant’s Immune Sys- tem? Paul A. Offit, Jessica Quarles, Michael A. Ger- 3. Immunization Safety Review Committee, Board ber, Charles J. Hackett, Edgar K.Marcuse, Tobias R. on Health Promotion and Disease Prevention, Institute Kollman, Bruce G. Gellin, Sarah Landry Pediatrics Jan of Medicine (2004). Immunization Safety Review: Vac- 2002, 109 (1) 124-129. cines and Autism. Washington, DC: The National Acad- emies Press. ISBN 0-309-09237-X 13. Rothman, Kenneth J., Yinong Young-Xu, and Felix Arellano. “Age dependence of the relation between 4. Doja A, Roberts W (2006). “ and reassortant rotavirus vaccine (RotaShield) and in- autism: a review of the literature”.Can J Neurol Sci 33 tussusception.” Journal of Infectious Diseases 193.6 (4): 341–6. doi:10.1017/s031716710000528x. (2006): 898-898.

5. Lancet. 2010;375(9713):445. 14. Zipprich, Jennifer, et al. “Measles outbreak—Cali- fornia, December 2014–February 2015.” MMWR Morb 6. “Thimerosal in vaccines”. Center for Biologics Mortal Wkly Rep 64.6 (2015): 153-154. Evaluation and Research, U.S. Food and Drug Adminis- tration. 2007-09-06. Retrieved 2007-10-01 15. Takahashi, Saki, et al. “Reduced vaccination and the 7. Baker JP (2008). “Mercury, Vaccines, and Au- risk of measles and other childhood infections post-Eb- tism: One Controversy, Three Histories”. Am J Public ola.” Science 347.6227 (2015): 1240-1242. Health 98 (2): 244–53. doi:10.2105/AJPH.2007.113159. PMC 2376879. 16. Blume, Stuart. “Anti-vaccination movements and their interpretations.”Social science & medicine 62.3 8. Abdullah, Ahmad Badri. “Halal vaccine and the (2006): 628-642. Ethical Dimension of vaccination Programmes.” Islam and Civilisational Renewal (ICR) 5.3 (2014). 17. https://www.gov.uk/government/publications/ measles-confirmed-cases/measles-notifications-and- 9. Genzel, Y. (2015), Designing cell lines for viral vac- confirmed-cases-by-quarter-in-england-2013-to-2015 cine production: Where do we stand?. Biotechnology Journal, 10: 728–740.

10. Hayflick, Leonard (March 1965). “The Limited in vitro Lifetime of Human Diploid Cell Strains”. Experi- 23 Issue 12/2016 Issue 12/2016 24

espite being implicated metabolic pathway, more than which the Kyn pathway has Din immune responses of 95% of Trp is catabolized [1]. been implicated include a number of normal body neurological disorders such functions as well as disease This pathway is a curious one as Alzheimer’s, AIDS-related processes, the kynurenine as it has the capacity to elicit dementia and schizophrenia (Kyn) pathway is known immune responses that may [7-8], as well as autoimmune amongst researchers only both protect or harm the body disorders such as cancer, if one has worked on it, or depending on the extent of allergy, arthritis and asthma topics related to it. Worse the activation of the pathway in which it has been gaining still, if one has not done as well as the cells it is traction [9-13]. any immunology-related activated in. One of the earliest research, one may never hear documented roles of the Kyn The Kyn pathway also of it although its implication in pathway was in bacterial contributes to the medicine is transdisciplinary infections [2]. Its role in other immunotolerance observed A ‘Trp’ to the in nature, extending beyond infectious diseases such as in pregnancy, where the a single disease. The Kyn HIV/AIDS and hepatitis, as well activation of this pathway pathway is essentially a as malaria, has since been suppresses the mother’s local metabolic pathway involving established [3-5]. The role of the immunity in the placenta, the amino acid, tryptophan pathway in the pathogenesis preventing the mother’s (Trp), which is an essential of dengue infections has also immunity from rejecting her Land of Kyns building block for proteins been suggested [6]. Other foetus, which would otherwise (see Figure 1). Through this pathological conditions in be recognised as a foreign

Felicita Fedelis Jusof

At a Glance:

Breakdown of the amino acid tryptophan through the kynurenine pathway impacts a plethora of immunological processes, ranging from the starvation of invading bacteria to the induction of immunotolerance and the modulation of neurological diseases. Figure 1: Diagram of the Kyn pathway 25 Issue 12/2016 Issue 12/2016 26 Different Journeys:

body [14]. This discovery was mechanism through which and heart, an alternative role for not all cell types express enzymes monumental in contributing to the Kyn pathway exerts TDO in these tissues has been our understanding of how the an immunomodulatory considered [23,24]. IDO1, on the “ pathway modulates immunity. effect is either through the other hand, which is expressed downstream in the [kyns] pathway A similar mechanism of suppression of immune cells constitutively in relatively “ immunotolerance has been known as T cells or through low levels in the epididymis, documented in cases of the generation of metabolites intestine and placenta, is transplantation, where that can act on neurons [19- induced in various cells and induction of Trp-catabolic 21]. These metabolites may tissue types in the presence enzyme rendered protection either be neuroprotective or of inflammatory stimuli, namely from organ rejection in cases neurotoxic. interferon gamma (IFNᵧ), TNF of liver transplantation [15]. and LPS [14, 25-27]. The ability of this pathway to The first step in this pathway induce immunosuppression is the conversion of Trp to The least understood of the may possess functions aside kynurenic acid, quinolinic acid in the pathway, such as also contributes to a poorer kynurenine (Kyn). This step of three is the isozyme of IDO1, from its ability to metabolise and picolinic acid. Of these, quinolinic or picolinic acid, as outcome in several types of the pathway can be catalysed IDO2. Based on the most Trp. The expression of IDO2 kynurenic acid (KA) has been the downstream enzymes of cancers as it allows the tumour by three enzymes, tryptophan recent phylogenetic study, protein has been confirmed reported to be neuroprotective the pathway are either inactive, to persist in the host [16-18]. 2,3 dioxygenase (TDO), it is shown that IDO1 is more only in the mammalian liver [37,38], whereas downstream absent or present in levels indoleamine 2,3 dioxygenase similar to the ancestral IDO while its presence in other metabolites of the pathway, too low to exert an effect. One of the first mechanisms 1 (IDO1) and the most recently gene and that IDO2 arose tissues are ambiguous, as its 3-hydroxykynurenine, quinolinic Human foetal brain cultures proposed through which the Kyn discovered IDO2. While the from duplication of the RNA has been detected in acid (QA) and picolinic acid and lung cells also exhibited pathway exerts its immunological three enzymes catalyse the ancestral gene that occurred kidney, brain, colon as well as (PA) have been shown to exert similar features [42,42]. On response involves the same reaction, their distribution in early vertebrate evolution in epididymis [29,30]. IFNᵧ- neurotoxic effects [19,39]. the other hand, macrophages, manipulation of Trp availability and role in tissues differ. The with IDO1 being eventually inducible IDO2 was detected monocytes, microglia and liver to cells and pathogens in longest known enzyme of lost in a number of the lower in antigen-presenting dendritic Fascinatingly, not all cell cells were reported to have the m icroenvi ron ment. the three, TDO is expressed vertebrates [28]. Despite both cells, macrophages, astrocytes types express enzymes a high level of quinolinic acid, As Trp is a food source for constitutively in high amounts IDO homologues in mammals and mesenchymal stem cells downstream in the pathway. indicating the capacity of these pathogens in infections, the in the mammalian liver and its possessing striking genomic [31-33]. In terms of clinical In cells where enzymes cells to metabolise substrates activation of this pathway best-understood role is in the structural similarities and significance, IDO2 has been downstream in the pathway downstream of the pathway during microbial infections regulation of dietary Trp [22]. Trp-catabolic properties, the implicated in some forms of are absent or present in very [40, 42,43]. strategically depletes Trp, However, as it also is expressed enzymatic activity of IDO2 is cancer [32-34]. However, more minute levels, the Kyn pathway effectively starving and constitutively albeit at low relatively low and its substrate recently, it was also reported to often does not metabolise ow is this pathway relevant eventually eliminating the levels in other tissues such as specificity differs from IDO1, be involved in the pathogenesis substrates beyond kynurenine. Hto the Malaysian context, pathogens [2]. The alternative epididymis, testis, pancreas leading to speculations that it of rheumatoid arthritis and For example, in endothelial one may ask. contact hypersensitivity cells, Trp is catabolised to [35,36]. kynurenic acid constitutively The involvement of this pathway The generation of neuroactive while generating both in immune responses of Pathogens, Take a Hike! metabolites through the Kyn kynurenine and kynurenic acid various diseases reflects pathway are known to contribute when primed with IFNᵧ [40,41]. the potential of this pathway to the progression of some of However, endothelial cells to help us better understand Trp is a food source for pathogens in infections, the diseases it is implicated do not possess the capacity more than just one immune- “ in. These metabolites to synthesise kynurenine and inflammation-related the activation of this pathway ... depletes Trp, include 3-hydroxykynurenine, metabolites downstream disease. The major health effectively starving and eventually eliminating the pathogens “ 27 Issue 12/2016 Issue 12/2016 28 About

burden of Malaysia according the neurotoxic metabolites, or this pathway may help us with to the National Strategic Plan for administering neuroprotective the diagnosis and treatment of Non-communicable Disease, metabolites could be more than one physiological or Ministry of Health Malaysia, is a possible approach to pathological condition. The Author non-communicable diseases intervention. The most exciting which include cardiovascular- thing about deepening our related illness, diabetes and understanding of this pathway cancer [44]. In addition to is the potential to apply the these non-communicable knowledge in more than just diseases, infectious diseases, one disease. namely dengue and HIV/AIDS, Dr. Felicita Fedelis Jusof considers rounds up the eight leading The remarkable thing herself a newbie in the academic world. Having disease burdens of Malaysia. about research is that the completed her doctoral degree in the University Strikingly, the Kyn pathway has solutions are never quite of Sydney in the year 2015, she returned to been implicated in all of the straightforward and often above mentioned diseases. enough, the direction a study serve the very people who funded her doctoral It has been suggested that takes can be unpredictable degree overseas (Malaysian taxpayers) through the balance between the and surprising. The best of her service to the University of Malaya. Although neuroprotective and neurotoxic research projects begins with she loves the Big Bang Theory, she sees herself metabolites generated by the a very simple yet logical and as an ordinary person who enjoys normal pathway could be used for exciting idea which, with further things like The Voice, amazing Asian food and early diagnosis, prognosis persistent probing, yields and intervention in diseases in valuable information for our Ed Sheeran. Despite this normalcy, she can which Kyn pathway is involved. understanding of the human sometimes be accused of being an adrenaline It would be interesting to body and disease processes. junkie who enjoys bungee jumping, bridge investigate if the balance climbing and slingshot rides to name a few. between the neuroprotective Perhaps this is the vision that the and neurotoxic metabolites understanding of kynurenine influences the progression of pathway and the key players these diseases and whether in it calls us to. That one day, inhibiting the generation of a better understanding of 29 Issue 12/2016 Issue 12/2016 30 References

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43. Heyes MP, Chen CY, Major EO, Saito K. Different kynurenine pathway enzymes limit quinolinic acid formation by various human

Written by Tan Choo Hock 33 Issue 12/2016 Issue 12/2016 34

At a glance to toxins in the venom, forming to ensure effective treatment, ites from venomous universal antivenom, as the inactive immunocomplexes and this is attributed to the vast that can be eliminated through variations in the composition of snakes can lead effectiveness is limited by the phagocytosis. Clinically, this venoms from different or even a Bto snakebite different snake species and neutralises the toxicity caused same species. Venom variations envenomation (not poisoning), their geographical locality. by venom, either by reversing or can manifest as differences in and antivenom is the only The production and use of halting the progression of venom the subtypes of toxins, their definitive therapy to date. antivenoms can be optimised toxic effect. relative abundances, peptide Antivenoms used in current by unravelling the complexity sequences and even the epitopes. clinical practices are derived of venoms, especially their wo all-time pertinent The ramification of venom from antibodies of animals immunogenicity and the challenges surrounding variation is far-reaching as it can (e.g. horses) that have been dynamics-kinetics of venom- Tthe use of antivenom are: lead to discrepancies in clinical immunised with one or a mix of antivenom interplay. (1) the effectiveness or quality presentation and syndrome snake venoms. However, the of antivenom; (2) the availability progress, as well as suboptimal production of these biologics of antivenom [3]. There is no response to antivenom especially is highly costly, and there is no universal antivenom or antidote, when the antivenom used was despite claims by some traditional produced for a different species medicine providers. The use of or from a distant country [3-5]. antivenom is species-specific This explains the importance

eared or loved, reviled or revered, anaging snakebite envenomation the snake is a significant yet takes on multiple steps; antivenom Fmystical subject throughout human Mremains the definitive and civilisations. There are more than 3,000 etiological therapy. Antivenom is perhaps snake species in the world. About 600 one of the oldest “antibody-based species of these are venomous and over treatments”, pioneered by Albert Calmette 200 are considered medically important (recalling: BCG vaccine) in the late 19th – their bites can cause envenomation, century, which principle still applies today a condition characterised by the in the treatment of snakebites – while development of systemic or local toxicity immunotherapy against infections (e.g. due to the venom’s effect [1]. Snakebite diphtheria) has basically been replaced envenomation is prevalent in many tropical by vaccination. Vaccination against snake and subtropical countries, affecting venom is still controversial and has not mainly the poor rural populations. been proven effective in the earlier trial. Worldwide, the annual mortality rate Antivenoms thus remain important, has been estimated to be around 100,000 relevant, and life-saving to date. They are deaths [2]. Unfortunately, the persistent derived from animals (typically horses) underreporting/underestimation of its that have been hyperimmunised with true has made it the most venom(s) of a single species (thus raising neglected disease condition, and ironic monovalent/monospecific antivenom) or enough, this is further aggravated by its several species (thus raising polyvalent/ removal from the WHO-list of neglected polyspecific antivenom). Current tropical diseases in 2015. technologies process antivenoms in three main forms: whole immunoglobulin, the antigen-binding fragment (Fab), or the Figure 1: A marine (left) and an arboreal (right) snake were identified and carefully dimeric form F(ab’)2. They act by binding milked for their venoms by the author. Snake species identity and their habitat location are important information for Dr Tan’s research, as venom toxins can vary significantly among snakes. 35 Issue 12/2016 Issue 12/2016 36

of species recognition in envenomation further aggravates the already inadequate cases, as inappropriately administered supply of antivenoms in many regions of antivenom would not only be futile in the world. Note, although antivenoms rescuing the victim but also increases the are generally in high demand globally, medical cost and exposing the patient unlike any other generic medicines, their to unnecessary risk of adverse effects of formulations are limited by species and antivenom, for instance, hypersensitive locality of concern, practically making reactions that can be fatal. Nevertheless, each product some kind of an orphan certain venoms share similar toxin profiles drug – so, to produce or not to produce and hence may be cross-neutralised by a an expensive treatment to cater for a small specific antivenom - for example, the market (limited by different snake species monocled cobra antivenom manufactured and geography) for consumers who are in Thailand is effective in treating mostly poor – this is a serious but realistic neurotoxic envenomation by the equatorial question to answer. In Malaysia, the local spitting cobra in Malaysia [6]. For pit viper antivenom production facility has long envenomations, venoms of the Malayan been closed down, and the country has pit viper and the Asiatic lance-headed pit been relying on imported antivenoms for vipers of Trimeresurus complex , although the past few decades. This is a solution that exhibiting similar hemotoxic effects, have many countries have adopted, however, substantial antigenic differences in toxins the quality and effectiveness of these that the respective specific antivenom imported antivenoms, which were raised does not cross-neutralise each other well, from different species (although may be therefore warranting the use of different closely related) from foreign lands, must specific antivenoms [6]. be first rigorously tested at the laboratory level to provide insights into the suitability n the other hand, antivenom for use in local cases. In recent years, manufacturing is highly costly and with the available emerging laboratory Otechnically demanding. Several evidence and favourable clinical antivenom plants closed in recent years observations, Malaysia is moving towards ostensibly for the high production cost and the use of some antivenoms produced limited market demand by region. This in Thailand for the common and closely

Figure 2: Feared or loved, but rarely understood – venomous snakes do not prey on humans and envenomations are usually results of unpleasant encounters between humans and snakes – feeling threatened, the fangs (in this picture, a pit viper with its front fangs shown) and the venom channelled through them become the best bio-weapon for the snake. Venoms leave an impact on human lives in a paradox: the side that can kill and destroy, and the other side that serves as a rich pool of novel bioactive compounds, from which drug discovery can be made.

Figure 3: Examples of local “haemotoxic” snakes: Malayan pit viper (left) and Cameron Highland pit viper (right). Envenomation by these species can cause similar pattern of bleed- ing disorder, but requires different kind of monovalent antivenom for effective treatment due to the differences in the molecular makeup of their venom toxins. 37 Issue 12/2016 Issue 12/2016 38

related species shared by the two countries concerns the community most. Recently, the REFERENCES in close proximity [5-7]. Patients envenomed group has also identified some of the limiting by some of the species in Malaysia can factors in governing the immunogenicity benefit from cross-neutralisation conferred of venom used in the production of by certain Thai antivenoms, due to the antivenoms; research is now on-going to [1] WHO. (2010). Guidelines for the transcriptome and venom proteome of conserved antigenicity of principal toxins in strategise an approach that can overcome Management of Snake-bites. World the Malaysian king cobra (Ophiophagus Health Organization: Regional Office for hannah). BMC Genomics, 16:687 the different lineages. the limitation of antivenom effectiveness South-East Asia. [12-15]. It is hoped that the findings will be [9] Tan, C. H., Tan, K. Y., Lim, S. E., n this context, it should be noted that translated into a trans-border, pan-region [2] Kasturiratne, A., Wickremasinghe, & Tan, N. H. (2015). Venomics of the A. R., de Silva, N., Gunawardena, N. K., beaked sea snake, Hydrophis schistosus: Professor Tan Nget Hong from the collaborative research that will eventually Pathmeswaran, A., Premaratna, R., . . . A minimalist toxin arsenal and its IUniversity of Malaya (UM) has led seek the production of an affordable, “broad- de Silva, H. J. (2008). The global burden cross-neutralization by heterologous venom research in Malaysia for almost 40 spectrum” antivenom with high potency of snakebite: a literature analysis and antivenoms. Journal of Proteomics, years. Established recently, the Venom and multiple species coverage. In addition, modelling based on regional estimates of 126:121-130. envenoming and deaths. PLOS Medicine, and Toxin Research Laboratory (VTRL, the data generated by the group may be 5(11):e218. [10] Tan, N. H., Fung, S.Y., Tan, K.Y., Faculty of Medicine, UM), which the useful for future studies in drug discovery, Yap, M.K.K., Gnanathasan, C.A., Tan, author of this article is co-leading, has been biodiversity and wildlife conservation. Thus [3] Williams, D. J., Gutierrez, J. C.H. (2015). Functional venomics of continuously researching on snake venoms far, the group has unveiled the functional M., Calvete, J. J., Wuster, W., the Sri Lankan Russell’s viper (Daboia Ratanabanangkoon, K., Paiva, O., . russelii) and its toxinological correlations. and antivenoms to unravel the complexity of venom proteomes (with or without venom- . . Warrell, D. A. (2011). Ending the Journal of Proteomics, 128:403-423. snake venom toxins and the myth of venom- gland transcriptomes) of several important drought: new strategies for improving the antivenom interactions. Findings that have lineages, including the monocled cobras flow of affordable, effective antivenoms [11] Tan, C. H., Fung, S. Y., Yap, M. K., in Asia and Africa. Journal of Proteomics, Leong, P. K., Liew, J. L., & Tan, N. H. been published include the transcriptomics (from Malaysia, Thailand and Vietnam), 74(9):1735-1767. (2016). Unveiling the elusive and exotic: and proteomics of several major or exotic king cobra (Malaysia), hump-nosed pit viper Venomics of the Malayan blue coral snake species in the region [4, 8-11]. Coupled with and Russell’s viper (Sri Lanka), equatorial [4] Tan, K. Y., Tan, C. H., Fung, S. (Calliophis bivirgata flaviceps). Journal of functional, in vitro/in vivo characterisation spitting cobra (Malaysia), beaked sea snake Y., & Tan, N. H. (2015). Venomics, Proteomics, 132:1-12. lethality and neutralization of Naja of the venoms and their antivenom (Malaysia) and the exotic Malayan blue kaouthia (monocled cobra) venoms from [12] Tan, C. H., Tan, N. H., Tan, K. Y., & neutralisation profiles, the group is coral snake (Malaysia) [4; 8-11]. three different geographical regions of Kwong, K. O. (2015). Antivenom cross- determined to provide detailed insights into Southeast Asia. Journal of Proteomics, neutralization of the venoms of Hydrophis 120:105-125. schistosus and Hydrophis curtus, two the pathophysiology of envenomation and common sea snakes in Malaysian waters. how treatment can be optimised - this aspect [5] Tan, K. Y., Tan, C. H., Sim, S. Toxins (Basel), 7(2):572-581. M., Fung, S. Y., & Tan, N. H. (2016). Geographical Venom Variations of [13] Wong, K. Y., Tan, C.H., Tan, N.H. the Southeast Asian Monocled Cobra (2016). Venom and Purified Toxins of (Naja kaouthia): Venom-Induced the Spectacled Cobra (Naja naja) from Neuromuscular Depression and Pakistan: Insights into Toxicity and Antivenom Neutralization. Comparative Antivenom Neutralization. The American Biochemistry and Physiology - Part C: Journal of Tropcal Medicine and Hygiene, About The Author: Toxicology and Pharmacology, (In press). (In press). doi:doi:10.4269/ajtmh.15-0871. doi: 10.1016/j.cbpc.2016.03.005. [14] Tan, K. Y., Tan, C. H., Fung, S. [6] Tan, C. H., Tan, N.H. (2015). Y., Tan, N. H. (2016). Neutralization Toxinology of Snake Venoms: of the principal toxins from the venoms Dr. Tan Choo Hock (MBBS, PhD) is a Senior Medical Lecturer The Malaysian Context. In P. of Thai Naja kaouthia and Malaysian in Pharmacology from UM. His research interests span a wide range of topics in Gopalakrishnakone, H. Inagaki, A. Hydrophis schistosus: Insights into toxinology, including molecular and functional characterisation of venoms, antivenom K. Mukherjee, T. R. Rahmy, & C.-W. toxin-specific neutralization by two Vogel (Eds.), Snake Venoms (pp. 1-37): different antivenoms. Toxins (Basel), 8:86. pharmacology, and the “-omics” of venomous species. He enjoys passionately his Springer Netherlands. doi:10.3390/toxins8040086. research activities, from collecting samples in the wild to experiments conducted in the laboratory. He can be reached at [email protected]. Find out more [7] Leong, P. K., Tan, C. H., Sim, S. M., [15] Ratanabanangkoon, K., Tan, K. Y., Fung, S. Y., Sumana, K., Sitprija, V., & Eursakun, S., Tan, C. H., Simsiriwong, about the author by visiting his profile at: Tan, N. H. (2014). Cross neutralization of P., Pamornsakda, T., Wiriyarat, W., common Southeast Asian viperid venoms Klinpayom, C., Tan, N. H. (2016) A http://www.scientificmalaysian.com/members/tanchoohock/ by a Thai polyvalent snake antivenom Simple and Novel Strategy for the (Hemato Polyvalent Snake Antivenom). Production of a Pan-specific Antiserum Acta Tropica, 132:7-14. against Elapid Snakes of Asia. PLOS Neglected Tropical Diseases, [8] Tan, C. H., Tan, K.Y., Fung, S.F., 10(4):e0004565. doi: 10.1371/journal. Tan, N.H. . (2015). Venom-gland pntd.0004565. 39 Issue 12/2016 Issue 12/2016 40

Disclaimer: In a wasteland, and at a time where The following article is a vaccination was illegal, a boy named fictional piece that may or Mikhail was destined to save the last piece may not be scientifically of humanity. accurate. Reading with It started in 2016, when more and more discretion is advised. parents refused to get their children vaccinated, claiming that immunised children were unhealthy and at risk of go to, and no entertainment to cheer anyone developing chronic diseases later in life. In up. The only entertainment available was a mere three months, the propaganda had the news, which only existed to inform the spread to Asia, including Malaysia. In the citizens about the current death toll. People year 2050, 98% of parents worldwide were were quarantined inside their own homes. against vaccination. Petitions were signed globally and governments were forced to de- It was Armageddon.

legalise vaccines in the name of democracy.

“I’m next!” Mikhail was frantic. He had just

By 2051, epidemics began to occur. witnessed his neighbour’s son, a boy around

The Imitation his age dropping dead right before his eyes Born to a genius scientist, and a through his bedroom window. The Imitation remarkable ex-navy Lieutenant, Mikhail’s

parents were a part of the 2% of the human “We will not let anything happen to you,” population that still practiced vaccination. consoled Diana, Mikhail’s mother. Knowing what would happen, Mikhail’s father invented a super vaccine — AFOV, also “Everyone I know is dead,” Mikhail gasped. known as ‘All-for-One-Vaccine’ — to fight off “I’m going to die soon, just like them.” all communicable diseases. When Mikhail By Nur Atikah Abdullah, Charles George Gajim & Seti Faezah Rosli was born in 2050, he was vaccinated with “Son, there is something you should know,” AFOV by his father, making him immune to Mikhail’s father said calmly, seemingly the worldwide epidemics that had begun to unaffected by his son’s outburst. plague the world’s population. Learning the truth about himself was by Twenty years later, the world had changed far the most shocking event in Mikhail’s life. At a Glance: dramatically. Things had gone from bad According to his father, the SIC plague was to worse and many people who were born the least of his worries. Thanks to a vaccine after the year 2050 had succumbed to called AFOV, created in secret by Mikhail’s The idea of vaccination has always been epidemics. The deadliest of them all was father and given to him as a child, Mikhail heavily debated throughout the past few a new plague called Severe Intravascular was resistant to the plague and other decades. Back in the year of 2016, more people Croatoan or famously known as SIC, which diseases as well. He was not immortal by was wiping out the world population every started to reject the idea of vaccination, any means, but at least, he was safe. day. By the time someone realised what claiming that immunised children were was happening, it was too late. There just Nevertheless, he was restless. He was unhealthy. By the year 2050, the vaccination weren’t adequate resources to formulate a certainly safe, but what about others? The was permanently banned by governments all cure for it, let alone a vaccine. plague began with fever, but the symptoms over the world. However, a little boy named progressed dramatically in the victims. In Every nation in the world was hit by the a matter of time, the blood vessels would Mikhail was raised and secretly immunised by plague. There was no food to eat, no jobs to burst, mimicking a haemorrhagic stroke. his parents with a vaccine called AFOV (All- Some took months to reach the final stage, for-One-Vaccine). It is the only cure against while the unlucky ones only had days. Those who were infected never made it to a new emerging disease called SIC (Severe another year. He couldn’t bear seeing any Intravascular Croatoan). By extracting the more people die. He couldn’t just sit and do antibodies from his blood, replicating it and nothing while others fought for their lives then silently distributing it to those in need, each day.

Mikhail vowed to save the last of mankind. He had to think of something.

41 Issue 12/2016 Issue 12/2016 42 22

He had to do something.

“Are you sure you want to do this?” Diana appeared hesitant.

“This is the only way we can stop this, Mom. We can end this once and for all,” replied Mikhail.

“You have to be cautious. If you were to be caught, you would be their lab rat, you would be a precious test subject for their everlasting experiments,” said his Dad, voicing his doubts.

“With all the physical activity training I’ve done with mom since I was four to keep me fit and athletic, and the homeschooling from you, Dad, I will be fine. I am the ultimate combination of brain and brawn, aren’t I?” Mikhail said confidently.

“What is your plan?”

“Dad, you can extract the antibodies from my blood, right? We can synthesise it and distribute it to everyone,” Mikhail said. “Carefully and stealthily,” he added to reassure his parents.

Mikhail began his mission in plain sight. He didn’t use any costume to do his job. He wasn’t planning to be a superhero wannabe but he did do his best to conceal his identity. Every day after sundown, he would visit those who were infected and give them a vial of ready-made antibodies. With it, people were progressively getting better. They started calling him a vigilante since he wasn’t exactly a law-abiding citizen. He didn’t mind being a vigilante for the rest of his life as long as he could help https://twitter.com/ScientificMsian people. https://www.facebook.com/scientificmalaysian

It took years before the SIC plague was completely eradicated. https://plus.google.com/u/0/109448324092897722869

Nonetheless, people finally learned their lesson about the importance http://www.linkedin.com/groups/Scientific-Malaysian-4043956 of vaccination.

ABOUT THE AUTHORS:

Nur Atikah Abdullah, Charles George Gajim, and Seti Faezah Rosli are Bachelor of Biomedical Science final year students at Management and Science University (MSU), Shah Alam. All three of them have also previously studied Diploma in Medical Laboratory Technology. Their final year research projects comprise many research fields such as anatomy, pharmacology, and microbiology. Nur Atikah enjoys reading and writing fiction, Charles is into sports especially basketball, while Seti Faezah likes cooking. Find out more about the authors by visiting their profiles at:

http://www.scientificmalaysian.com/members/abdullahika/ http://www.scientificmalaysian.com/members/c90kidz04/ http://www.scientificmalaysian.com/members/iradiana/

Issue 11/2015 43 Issue 12/2016 Issue 12/2016 44

Our immune system is naturally gifted with remarkable specificity, potency and memory. So far, no pharmacological treatment for any diseases could possibly provide comparable level of safety, efficacy and lasting effect as the human immune response. In the treatment of cancer, after the primary therapies – i.e. surgery, radiotherapy and chemotherapy – immunotherapy is being explored as a fourth option, especially for advanced stage cancers. To date, several kinds of novel immunotherapeutics, including cancer peptide vaccines, dendritic cell vaccine, immune checkpoint blockade and adoptive cell therapy are increasingly being introduced in clinics. This article peeks into the brief history of immune-stimulation, state-of-the-art advances, as well as some limitations of these approaches.

Of Spontaneous Cancer Regression and Coley’s Toxins In the unavailing search Indeed, Dr. William Coley, led to stimulation of some for a cancer cure, it has an orthopaedic surgeon, was type of immune responses. been interestingly noted one of the first physicians to In an attempt to rationalise that certain cancers could relate the concept of immune his hypothesis, series of spontaneously regress. system and its interface with experiments to deliberately Albeit rare and only cancer by leveraging on the infect cancer patients with Teaching anecdotally reported, kidney, serendipitous discovery of S. pyogenes were carried brain (neuroblastoma), the record of an immigrant out and resulted, at times, uterine and skin cancer are patient with a recurring in failed infections or even amongst the four frequent sarcoma that spontaneously death. Eventually, a version cancers associated with regressed following an containing a mixture of killed cancer regression, according extended postoperative S. pyogenes and Serratia Your Immune to a review of 176 published surgical wound infection with marcescens was developed cases from 1900 to 1960 [1]. Streptococcus pyogenes [3]. into what became known The sudden disappearance It was documented that the as the ‘Coley’s toxins’. While of not only the primary tumour, despite only partially remarkable recoveries were tumour but also their removed, shrank over documented in several cases metastatic foci has been several months and finally of advanced diseases [5], System To hypothesised to be a result of disappeared completely. its use eventually faded for unexpected activation of the Following discharge, he various reasons. immune system leading to remained cancer-free in the the recognition of non-self- subsequent reviews. Penned proteins and subsequently in his paper dated back in Fight Cancer the destruction of these 1893 [4], Coley attributed the cancer cells [2]. patient’s unexpected cure to the infection which likely By Litt-Yee Hiew 45 Issue 12/2016 Issue 12/2016 46

Harnessing the Natural Capacity of the Cancer Immunotherapy: From Immune System Experimental to Mainstream

However, it was not until editing” [8]. In other words, respectively, and function in Over the years, intense tumour-specific antigens that the treatment of advanced the middle of 20th century cancer that present as an antigen-specific manner. research effort to identify are solely expressed on the prostate cancer [19]. when the term “immune- clinically detectable mass Although various innate immunogenic targets cancer is crucial. Though Specifically, sipuleucel-T surveillance” was coined by are likely to have progressed and adaptive immune recognisable by the T-cells this ideal is rarely achieved, involves autologous cell immunologists Lewis Thomas beyond the initial stage of cells contribute to anti- has identified several certain TAA, e.g. CT antigens transplantation of peripheral and Macfarlane Burnet [6, 7]. carcinogenesis that render tumour immunity, current human tumour-associated and mutated antigens were blood monocytes primed Accordingly, the host immune them capable of evading the available evidences strongly antigens (TAAs) such as found to be expressed only with a fusion protein system is deemed capable imposed immune equilibrium suggest T-cell responses cancer-testis (CT) antigens. in certain cancer cells and consisting of recombinant of constantly monitoring to achieve invasion and specific to tumour antigens Like the predecessors of are therefore plausible prostate acid phosphatase and blocking cancerous cell metastasis. can mediate spontaneous existing immunotherapies, target as well [15]. Given (another TAA expressed in development by detecting tumour clearance [9, 10]. To cancer immunotherapy was the propensity of viruses prostate tumour cells), as well mutated cells and eliminate At its core, the human evoke T-cell activation, two in favour of the humdrum to efficiently induce CTL as granulocyte-macrophage them through various immune system is composed signals are indispensable: concept of reinforcing the production, these antigens colony-stimulating factor. mechanisms. Nonetheless, of both innate and adaptive one of which is the signal host immune response to were delivered using selected On the other hand, mutated with emerging mutations, immunity. Phagocytes and through T-cell receptor (TCR) eliminate cancer cells and recombinant viral vectors antigens, also known as neo- some may incidentally evade natural killer cells are effectors induced by the complex of produce lasting immunity and adjuvants. One such antigens, refer to antigens immunosurveillance and of innate immunity which antigenic peptide and major [11]. It, therefore, seems example is PROSTVAC, a derived from tumour- continue to expand. Such recognise target antigens histocompatibility complex logically sound to evoke T-cell pox virus-based prostate specific genomic DNA consequent development in a non-specific manner. while the other is through responses against these cancer vaccine containing mutations. Because they of resistant mutant selected Cytotoxic T-cells (CTLs) and surface molecules termed tumour antigens through prostate-specific antigen possess epitopes that are by the continuous pressure antibodies, on the other stimulatory co-receptors, such vaccination or similar [16] which demonstrated specific to individual tumour from the host immune system hand, are effectors of cellular as CD28, 4-1BB and OX-40. mechanisms. One option an improved overall and [20], hence the induction are referred to as “immune- and humoral immunity, for developing vaccines for median survival in phase II of neoantigen-specific infectious diseases includes testing in advanced stage effector T-cells may be less using the inactivated form patients [17] and is currently affected by T-cell tolerance of pathogen to stimulate tested in an ongoing phase compared with non-mutated immune response. However, III trial [18]. self-antigens. Notably, when a similar approach a recent publication has ..with emerging mutations, was employed to make Dendritic cell-based (DC- revealed an exciting finding “ tumour vaccines, it proved based) vaccine is another that complex tumours with ineffective. One prominent antigen-specific approach multiple mutations was some may incidentally example is the whole-cell but with the advantage of found to have an increased evade melanoma vaccine known bypassing the vectored chance of being spotted by as Canvaxin which, despite a delivery step. The DCs are the immune system [21]. and seemingly promising phase presented to the antigen immunosurveillance II studies [12], revealed no directly ex vivo and, following benefit in the subsequent priming, readministered phase III testing [13], back into the patient. continue to expand.” ultimately leading to its Notably, the only therapeutic discontinuation [14]. When cancer vaccine that has been such powerful-but-blunt licensed for clinical use so far approach failed, it led to the is the DC-based sipuleucel-T realisation that targeting (Provenge®) for used in 47 Issue 12/2016 Issue 12/2016 48 Overcoming the Inherent Immune Resistance in Established Cancers “...tumours could generate an Vaccines aside, alternative balance has a significant that facilitate immune immunologically-restrained milieu approaches include genetically stimulation-dominant side, escape. In order for tumours engineering patient’s own simply because providing to grow, the immune immune cells via tumour- adequate stimulatory co- system is often prevented by interfering with activated T-cells infiltrating lymphocytes signals to exceed the heavy from mounting an effective therapy or chimeric antigen inhibitory conditions in the antitumour response. In the receptor T-cells therapy to tumour microenvironment tumour microenvironment, through various signalling pathways that directly target cancer cells is particularly challenging this cancer-specific milieus [22]. While some cancers without introducing are formed by several cellular demonstrated satisfactory significant adverse effects to populations, including facilitate immune escape.” clinical response [23- the patient. tumour cells, stromal cells 27], they are relatively and infiltrating immune cells. uncommon [28]. In other The current understanding Accordingly, this response words, it appears that these of tumour immunology can be broadly categorised revealed that, notwithstanding antibodies against those unfortunately do not respond potent immune cells are proposes that tumours into a few phenotypes [29]. their presence, the T-cell response molecules have been developed well to these therapies, probably switched off by some tumour could generate an Notably, the T-cell infiltrated is in actuality blunted albeit being such as ipilimumab (anti- due to insufficient numbers or defence mechanisms. Indeed, immunologically-restrained phenotype has been largely reversible [34]. Further CTLA-4 antibody), nivolumab repertoires of neo-antigens to the immunosuppressive milieu, typically by interfering demonstrated to confer solid research eventually led to the and pembrolizumab (anti- evoke host immunity. Apart from condition in the tumour with any one of the following tumour a positive prognostic discovery of inhibitory receptors PD-1 antibody) which have CTLA-4, PD-1 and PD-L1, other microenvironment is steps, including the priming, value in colon, breast, skin such as immune checkpoint been approved for use in a immune checkpoint molecules amongst the most crucial recruitment, trafficking,(melanoma) and ovarian molecules, which were found to number of countries. Antibodies with potential as clinical targets factors that account for entry and accumulation of cancer [30-33]. Nonetheless, be highly expressed in tumour against programmed cell death include lymphocyte-activation ineffectiveness even activated T-cells through subsequent studies looking tissues and contribute to this ligand-1 (PD-L1) are also under gene-3, T-cell immunoglobulin when the therapeutic various signalling pathways at advanced melanoma immunosuppressive conditions development [39]. So far, mucin-3, and B- and T-lymphocyte [35, 36]. As a transducer of treatments with these antibodies attenuator [49, 50]. Research and co-inhibitory signals, these have shown promising results. development of those molecules immune checkpoint molecules Durable clinical response were are actively carried out at present. inherently exist to maintain noted in 15–20% of the patients immunological homeostasis to treated with CTLA-4 blockade limit over-activation of the host while anti-PD-1 notably reported immune systems. Hence, the a 3-year survival rate of up to 40% concept of immune checkpoint in advance stage cancers [40-43]. blockade is to induce therapeutic While not all agents necessarily benefit by counteracting the confer an overall survival (OS) immunosuppression in the advantage [44, 45], the long-term tumour microenvironment. survival benefit is unobserved in conventional therapies for which Two most representative the clinical responses, though immune checkpoint molecules, immediate, are commonly at present, are the cytotoxic transient. Despite longer OS T-lymphocyte-associated protein-4 has been reported in skin, lung, (CTLA-4) and programmed cell kidney and bladder cancer death-1 (PD-1) [37, 38]. Accordingly, [46-48], other types of cancers

Illustration by Mohd Arshad 49 Issue 12/2016 Issue 12/2016 50

Conclusions and Future Directions About The Author

The progression from clinical and clinical settings Alongside the rapid Litt-Yee Hiew is currently studying towards an MSc in Molecular Coley’s toxins to the myriad of have been reported, with advances in sequencing Medicine at the International Medical University. She finds great immunotherapeutic approaches DNAJB8-derived antigenic technologies, the knowledge fulfilment from unravelling the wonders of science as well as in creative under development today peptide being one example of of tumour immunology has writing that could foster meaningful dialogue and bridge the gap speaks profoundly of the a promising candidate for both been greatly expanded at the between the scientific community and society. Find out more about contribution of immunology colon and kidney CSC⁄CIC- molecular level. More than in the evolution of cancer targeting immunotherapy [52]. just providing an incentive Litt-Yee by visiting her profile at: therapeutics. Ultimately, for the development of novel http://www.scientificmalaysian.com/members/lyhiew/ whether T-cells are activated Indeed, the research on immunotherapies, a better or inactivated upon TCR cancer therapy has come mechanistic understanding ligation will depend on the a long way in the past few will allow clinician to delicate balance between the decades and each step of this stratify individual patients stimulatory and inhibitory co- journey has been marked by accordingly and exploit their signals. On the other hand, milestones that shaped the inherent immune capacity to References multiple lines of evidence current clinical approach [53]. complement the standard-of- 1. Everson, T.C. (1967). Spontaneous Held at the New York Academy of Eggermont, A., et al. (2012). Trial indicate that cancer stem- Still, the outstanding value care treatment. The synergy regression of cancer. Prog Clin Cancer., Medicine. New York Academy of watch: peptide vaccines in cancer like cells or cancer-initiating of Coley’s immunotherapy of modulating various arms 3: 79-95. Medicine: Symposia of the Section therapy. Oncoimmunology., 1: 1557- cells (CSC⁄CIC) – which are regimen, perhaps more than of immunity for potential on Microbiology, No. 9. New York, NY: 76. notoriously resistant to the any existing therapeutics, incorporation into the existing 2. Papac, R.J. (1998). Spontaneous Hoeber-Harper., 529-532. regression of cancer: Possible 12. Morton, D.L., Hsueh, E.C., current standard therapies, stemmed from the observed surgery, chemotherapy, mechanisms. In Vivo., 12: 571-578. 7. Burnet, M. (1957). Cancer: A Essner, R., et al. (2002). Prolonged including molecular-targeting clinical recoveries even in targeted therapy and biological approach. I. The processes survival of patients receiving active therapy – also express several advanced diseases, with such radiotherapy may hold great 3. Hoption Cann, S. 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SUMMARY

on-vaccine approaches for tackling such a highly effective vaccine, we should Nmalaria have made an impact consider RTS,S/AS01 as complementary in reducing the number of malaria to existing malaria eradication programs. cases and deaths but a vaccine would Current help tremendously towards malaria Resistance towards antimalarial drugs elimination. New sources of funding such should be taken seriously as there are as those from the Bill and Melinda Gates currently no new effective drugs in the Foundation, pharmaceutical companies pipeline. A genetic surveillance of sampling and oil companies in the last decade has mosquitoes and pathogens such as those enabled rapid advances in malaria vaccine carried out by the Malaria Genomic progress development. We are likely to see the Epidemiology Network (MalariaGEN) is RTS,S/AS01 vaccine to be licensed for vital to map out any emerging resistance use in the next few years despite its low and to monitor outbreaks. Additionally, we efficacy. should actively monitor for counterfeit and substandard drugs. A more effective vaccine would be one on malaria that targets the parasite at multiple stages Finally, we need to invest more funding (i.e. the sporozoite stage, liver stage, and research into other malaria species, blood stage and transmission blocking). especially P. knowlesi and P. vivax species However, this would also be more difficult that are more prevalent than P. falciparum vaccines to develop and implement. Until we have in Malaysia.

By Adaikalavan Ramasamy 55 Issue 12/2016 Issue 12/2016 56

About Malaria

alaria is a mosquito-borne disease that Malaria could be prevented either by Mrepresents a major public health risk, eliminating the mosquitoes that act as the affecting nearly half the world population and vector for the parasites, limiting the spread of causes a significant economic burden. The the disease by rapid diagnosis and treatment World Health Organization (WHO) estimates of suspected cases or by using vaccines to approximately 214 million new malaria cases enhance the human immune system to kill and 438,000 malaria deaths worldwide in the pathogen rapidly. In reality, a combination 2015 alone [1]. Children under the age of 5 of all these approaches will be required to living in sub-Saharan Africa accounted for eliminate malaria. 70% of these deaths. Other high-risk groups include pregnant women, immunosuppressed individuals (e.g. HIV infected patients), travellers and the elderly.

MALARIA LIFE CYCLE

alaria is caused by the Plasmodium breaks out of the liver to infect red blood cells Mparasites transmitted by infected female to multiply again, causing red blood cells to Anopheles mosquitoes. A female mosquito burst, thus releasing the parasites back into the Figure 1: requires blood to produce eggs and through bloodstream. If another female mosquito bites the process of biting the parasite enters the the infected human at this stage, the mosquito The life cycle of malaria plasmodium host’s blood vessels, where it travels rapidly also becomes infected, thus completing the life (Image credit: OpenLearn Works) to the liver to mature and multiply. Then it cycle of malaria transmission (Figure 1). 57 Issue 12/2016 Issue 12/2016 58

Figure 2A: Endemicity map of the Plasmodium falciparum in 2010 (Image credit: The Malaria Atlas Project) 59 Issue 12/2016 Issue 12/2016 60

Figure 2B: Endemicity map of the Plasmodium vivax (bottom) in 2010 (Image credit: The Malaria Atlas Project) 61 Issue 12/2016 Issue 12/2016 62

Figure 3: Potential geographical range of the Plasmodium knowlesi parasite reservoir map in 2013 in Asia region (Image credit: The Malaria Atlas Project) 63 Issue 12/2016 Issue 12/2016 64

malaria, severe anaemia, respiratory These drugs are considered to be the most Different types of distress). However, early diagnosis can be effective antimalarial currently available difficult as the initial symptoms of malaria and contribute hugely to malaria reduction. are similar to flu. Malaria is confirmed However, counterfeit or substandard malaria either examining blood smear from finger drugs threaten to undermine this success. prick under a microscope (Figure 4) or Further, parasites that are resistant to these ix different species of (~20%) which is predominantly commercially available rapid diagnostic test antimalarial drugs have been reported in SPlasmodium are currently found in South America and Asia kits. Cambodia, Laos, Myanmar, Thailand and known to infect humans. (Figure 2B). Vietnam. This is worrying given that no Each species has a different However, the most common WHO currently recommends five new antimalarial drugs are anticipated in the geographical spread, life cycles, species in Malaysia [2] are P. Artemisinin-based combination therapies near future. incubation periods, disease knowlesi (38%), P. vivax (31%) for uncomplicated P. falciparum malaria. severity and treatment approaches. and P. falciparum (19%) [2]. Note P. falciparum is the most common that P. knowlesi traditionally species worldwide (~75%) and infected monkeys only but it has the main cause of severe and recently acquired the ability to complicated malaria (Figure infect humans as well and this is 2A). The second most common an emerging problem particularly species worldwide is P. vivax in Malaysia (Figure 3).

Malaria symptoms, diagnosis and treatment ymptoms usually begin between 10 - 30 skin lasting 2 - 6 hours) and sweating stage Sdays after being bitten. The symptoms lasting 2 - 4 hours. include fever, chills, headache, fatigue and Figure 4: vomiting. Classic hallmarks of malaria is a Early and accurate diagnosis is key to repeated cycle of cold stage (intense cold selecting the correct treatment, shortening Image of a blood film for microscope diagnosis (left). Blood smear from a P. falciparum and shivering lasting < 1 hour) followed illness duration and to prevent life- culture which shows several red blood cells with the pathogen inside them (right). by hot stage (intense heat, headache, dry threatening complications (e.g. cerebral (Image credit: Wikipedia) 65 Issue 12/2016 Issue 12/2016 66

Malaria control and elimination efforts in Malaysia RTS,S/AS01 vaccine alaria elimination programs However, these efforts require constant Mfocusing on mosquito control monitoring, funding and considerable tradename Mosquirix in Malaysia have been successful in foresight. Furthermore, majority of ( ) reducing the number of cases from malaria cases arise from remote areas ~50,000 in the early 1990s to ~5,000 in in Sabah and Sarawak where access 2012 with a corresponding reduction in remains difficult. A substantial portion TS,S/AS01 is a recombinant vaccine which malaria, severe anaemia, malaria hospitalization, deaths due to malaria per year from 43 of malaria cases (~30%) are “imported Rfuses the P. falciparum circumsporozoite etc, compared to the control group. The efficacy to 16 [2]. cases” – where migrant workers from protein with surface antigen from Hepatitis B was dropped to 27% in infants who received Indonesia and Philippines who acquire and adjuvanted with AS01 (to increase immune four doses (same schedule but starting at 6 weeks Elimination strategies include indoor malaria during home visit before response). The vaccine induces high levels of of life). Infants and young children who did not residual spraying, using insecticide returning to Malaysia where their access anti-circumsporozoite antibodies which can receive the fourth dose had an even lower overall treated bed nets and good and fast to medical doctors is more limited [2]. attack the parasite before it can invade the efficacy. There was an excess of febrile seizures management of malarial outbreaks. liver cells. It also provokes a strong CD4 T-cell within 7 days of vaccination in the children in response which can kill the parasite in the liver older groups compared to the control group. before it can break out of the liver. The European Medical Agency evaluated the This vaccine was developed by GlaxoSmithKline scientific merits of this vaccine and found that (GSK) over three decades with funding support the quality of the vaccine and risk/benefit profile from the PATH Malaria Vaccine Initiative (MVI) is favourable from a regulatory perspective. In and Bill & Melinda Gates Foundation. This is October 2015, the WHO reviewed the evidence the first malaria vaccine to have completed the and recommended large-scale implementation critical Phase 3 clinical trial enrolling over 15,000 pilots to replicate the protection reported in the Vaccine development for volunteers from 11 trial sites in seven African children aged 5 - 17 months who received the countries. Two age groups were included: infants 4-dose schedule [4]. GSK is now in the process aged 6 - 12 weeks and children aged 5 - 17 of planning Phase 4 study to further characterise malaria months with a median participant follow-up of the safety and effectiveness of RTS,S/AS01 accines have been generally vaccines will considerably enhance and 48 months [3]. vaccine. These studies are expected to eventually Vconsidered to be the cheapest and complement the malaria elimination recruit 800,000 children aged 5 - 9 months in 3 most effective public health measure for efforts. Numerous vaccines are in The best protection was seen in the children - 5 sites located in sub-Saharan with moderate many infectious diseases and malaria is development but they mainly focus recruited at ages 5 - 17 months who received high malaria transmission settings. no exception. They could be integrated on P. falciparum and target the parasite four doses (vaccination at 0, 1, 2, and 20 months along with the routine vaccination before they burst out of the liver. In after recruitment) with an overall efficacy of 39% schedule and could offer long lasting the following sections, we discuss the and significant protection (31.5%) against severe protection as well as herd immunity three most advanced and promising if sufficiently large proportion of the vaccines: RTS,S/AS01, ChAd-MVA population is vaccinated. Therefore, with MeTRAP and PfSPZ. the availability of affordable malaria 67 Issue 12/2016 Issue 12/2016 68

ChAd63/MVA ME-TRAP vaccine PfSPZ vaccine

iral vector vaccines use harmless (MVA), which is a type of smallpox fSPZ vaccine was developed by Sanaria and protection in 6 out of 9 volunteers who received Vand replication-defective vaccine, expressing ME-TRAP. This Pmade up of non-replicating irradiated whole four doses and 6 out of 6 volunteers who received viruses to carry and deliver pathogen heterologous prime-boost strategy sporozoites. Sporozoite is the plasmodium form five doses. Inspired by the success of this trial, sequences to train the human immune provokes strong immune response that leaves the mosquito during the feeding the PfSPZ Vaccine Clinical consortium has set-up systems. The viruses are chosen from with a good safety profile and used process and infects the liver cells. Sanaria currently seven different clinical trials in USA, Africa and non-human species so they are not as the backbone for many candidate collect sporozoites manually from dissecting Germany which will recruit at least 450 volunteers. neutralised too quickly and designed vaccines including dengue, flu, RSV salivary glands of mosquitoes and then irradiate to be harmless and replication- and more recently with Ebola. The and freeze them for vaccination. In an earlier study While the reported efficacy of this vaccine is deficient. Viral vector vaccines have control group consisted of 60 adult [7], they identified that administrating this vaccine very high, there are several criticisms. Collection been shown to induce potent T-cell males who received intravenously in non-human primates and mice of large amounts of sporozoite manually will be response [5] which is required to as placebo. All volunteers were given was far more immunogenic than subcutaneous or challenging for large-scale implementation and destroy liver cells that have been antimalarial drugs after vaccinations intradermal vaccinations. Sanaria is working on a robot to automate this infected with the parasites. to clear parasites and then monitored Next, they recruited and vaccinated 40 adults with process. The second criticism is that the vaccine for 8 weeks post MVA vaccination for different dosages and number of vaccines and requires super-cold liquid nitrogen which would Researchers from Jenner Institute, infections. then deliberately challenged with the pathogen to be logistically challenging in Africa. Finally, the University of Oxford and the Malaria assess efficacy [8]. Among individuals who received practicality of intravenous injection five times in Viral Vectored Consortium reported They found that vaccinations reduced the highest dose of the vaccine, they observed young children needs to be considered further. their findings from a Phase 2 trial [6]. the risk of infection by 67%. While They used a chimpanzee adenovirus these results are very promising, the (ChAd63), which is similar to human findings would need to be replicated common cold virus, synthetically in a much larger trial with longer constructed to express the highly follow-up and participants from conserved regions of malaria multiple sites with different malaria antigens called ME-TRAP to prime transmission rates. Furthermore, the 61 healthy adult males in Kenya. results need to be replicated in infants Eight weeks later, the volunteers and young children who are at higher were boosted with an attenuated risk of malaria infection. About The Author poxvirus Modified Vaccinia Ankara Adaikalavan Ramasamy is currently the Senior Leadership Fellow in Bioinformatics and heads the Transcriptomics Core Facility at the Jenner Institute, University of Oxford. His team uses gene expression as a tool to understand how the immune system responds to vaccination and why this response differs among individuals. Understanding the mechanisms of protection can help inform vaccine development for infectious diseases and cancer immunology. Adai and his team work on a broad range of novel and licensed vaccines in adults, children and livestock for many infectious diseases including malaria, TB, RSV, influenza and Ebola. Find out more about Adai by visiting his profile at: http://www.scientificmalaysian.com/members/adairama/ 69 Issue 12/2016 Issue 12/2016 70

References

[1] Fact Sheet: World Malaria Report 2015 (updated 9th December 2015) http:// The Dengue www.who.int/malaria/media/world-malaria-report-2015/en/

[2] Management guidelines of malaria in Malaysia, Ministry of Health Malaysia http://www.mediafire.com/?nl4c3fndvue1p

[3] RTS,S Clinical Trials Partnership. Efficacy and safety of RTS,S/AS01 malaria Vaccine vaccine with or without a booster dose in infants and children in Africa: final re- sults of a phase 3, individually randomised, controlled trial. Lancet. 2015 Apr 23. pii: S0140-6736(15)60721-8

[4] Malaria vaccine: WHO position paper – January 2016. http://www.who.int/entity/wer/2016/wer9104.pdf?ua=1 Dilemma:

[5] Ewer, K. J. et al. Protective CD8+ T-cell immunity to human malaria induced by chimpanzee adenovirus-MVA immunisation. Nature Communication. 4, 2836 (2013). Route to Prevention - [6] Ogwang, C. et al. Prime-boost vaccination with chimpanzee adenovirus and modified vaccinia Ankara encoding TRAP provides partial protection against Plasmodium falciparum infection in Kenyan adults. Science Translation Medicine 7, 286re5 (2015). Are We There Yet? [7] Epstein, J. E. et al. Live attenuated malaria vaccine designed to protect through hepatic CD8+ T cell immunity. Science 334, 475–80 (2011).

[8] Seder, R. A. et al. Protection against malaria by intravenous immunization with a nonreplicating sporozoite vaccine. Science 341, 1359–1365 (2013).

By Nor Ilham Ainaa Muhsin 71 Issue 12/2016 Issue 12/2016 72 Summary Global Burden of Dengue

Although the Phase III clinical studies showed that Dengvaxia® Dengue represents a global health time off work, impact on tourism was efficacious with satisfactory safety profile, we still have to issue as it is endemic in over 100 is difficult to quantify but likely to continue monitoring the vaccine for long-term adverse effect by countries, many with tropical and be very high and comparable to sub-tropical climate, and affects malaria or TB. The epidemiologic developing suitable models and active collaborations to decipher the nearly 40% of the world population and ecologic factors affecting immunological mechanisms that might be triggered by the vaccine. [1] (see Figure 1). The World Health the spread of dengue include We also require a thorough cost-benefit analysis to determine the best Organization estimates 50 - 100 urbanisation trends, global warming option for dengue vaccination program in Malaysia. Besides, we should million infections and 22,000 deaths and increased global travel, which not neglect other approaches such as vector control and dengue occur annually, commonly in have led to large epidemics with high hotspot identification that can benefit other mosquito-borne diseases children [2]. The economic burden mortality in Southeast Asia. due to diagnosis, hospital treatment, (e.g. malaria).

Figure 1: Distribution of global dengue risk (Source: http://www.eliminatedengue.com/our-research/dengue-fever) 73 Issue 12/2016 Issue 12/2016 74 Clinical Aspects of Dengue

Symptoms appear 3 to 14 days after There is currently no treatment for infection and can range from mild dengue fever but the symptoms can to high fever with severe headache, be managed and reduced by giving muscle and joint pain. Dengue intravenous fluid to counteract the Hemorrhagic Fever (DHF) is a severe fluid leak from blood vessels in the form of dengue and can result in critical defervescent phase. persistent vomiting, abdominal pain, bleeding and breathing difficulty.

Dengue Virus and Transmission

In 1903, it was demonstrated that cause dengue in 1944 and to that dengue fever was caused by date, four serotypes (DENV1 – 4) have a viral infection transmitted by been identified. These serotypes are mosquitoes during feeding [3]. The phylogenetically and antigenically primary mosquito species is Aedes distinct and therefore can be aegypti, which can also transmit the considered as separate viruses. , yellow fever and Zika Infection with one dengue serotype virus. can provide lifelong immunity against reinfection with that The dengue virus is a single positive particular serotype, but not against stranded RNA virus belonging to the the other serotypes. Secondary Flavivirus genus of the Flaviviridae infection by a different serotype family. (developer of contributed to the majority of DHF the oral polio vaccine) identified cases [4]. two serologically different viruses

Dengue in Malaysia

Malaysia ranks in the top ten outbreaks (Figure 2B and 2C). In countries (see Figure 2A) with the 2015, there were 120,836 cases with highest dengue infection and death 336 deaths (almost 330 cases and 1 Figure 2: A) The average annual number of dengue cases reported in the 30 in the world. The dengue hotspots death per day) due to dengue. This most endemic countries to the WHO between 2004 to 2010. (Source: www. are predominantly found in Klang outbreak was associated with a eliminatedengue.com), B) and C) Number of dengue cases and deaths in Valley (60%) followed by Johor switch in the predominant circulating Malaysia from 1995 – 2015. (Source: www.idengue.remotesensing.gov.my) (15%). Since 2013, Malaysia has serotype from DENV3 and DENV4 to been experiencing unprecedented DENV2 in early 2013 [5]. 75 Issue 12/2016 Issue 12/2016 76 Overview of Dengue Vaccine Development Phase III Clinical Trial Evaluation

Scientists have been trying to Several approaches have been Dengvaxia® successfully is summarised in Table 1. The data develop a vaccine for dengue since tried including live attenuated completed two phase III clinical for the Asian countries was stratified the early 1930s. There are at least (where the pathogen is made safe studies in 2014 with over 30,000 into the younger cohort (< 9 years) three main challenges for developing by mutation), inactivated (using participants. Participants in both and older cohort (> 9 years). an effective dengue vaccine. First, chemical, heat or irradiation), DNA trials received three doses of the one needs to achieve immunity vaccines and subunit vaccines. The vaccine over the course of a year. This is the first dengue vaccine toward all four serotypes (i.e. a most advanced vaccine to date is These studies aim to examine the to reach clinical Phase 3. The tetravalent vaccine) as secondary Dengvaxia®. We will now briefly efficacy of Dengvaxia® in reducing overall vaccine efficacy in the older infection with a different serotype review the vaccine construction virologically-confirmed dengue and cohort was encouraging (67.8% in leads to an increased risk of DHF. and the subsequent clinical trials DHF. The first trial included 10,275 Asian countries and 64.7% in Latin Secondly, it is difficult to achieve before discussing the merits of children aged between 2 to 14 years American countries). The most a balanced efficacy towards all implementation this vaccine in recruited from 11 sites in five Asian striking finding from this study is that four serotypes in a tetravalent Malaysia. countries. The second trial included the vaccine dramatically reduced the vaccine formulation due to serotype 20,869 children aged between 9 to incidence of DHF by more than 90%. interference. Finally, the lack of an 16 years from 22 sites in five Central animal disease model prevents the and South America countries. The However, there are several negative rapid testing of candidate vaccines. volunteers were randomised to findings from the trial. First, the vaccine and placebo groups in a 2:1 vaccine efficacy was low in the ratio. The interim result based on younger cohort (44.6%) which is 1-year-follow-up from final dose [7] the group at the highest risk. The Construction of Dengvaxia® Vaccine

The E and prM gene in the In early 2000, scientists from dengue virus have been identified Acambis (now acquired by Sanofi- as essential for dengue vaccine Pasteur, a French pharmaceutical construction [6]. The E gene company) adopted the strategy to encodes the envelope glycoprotein, incorporate these two genes into which stimulates the production of a 17D strain neutralising antibody in humans. The genomic backbone (see Figure pre-membrane protein (encoded by 3) to produce a recombinant, live- the prM gene) is required to process attenuated, tetravalent dengue and fold the E protein into the correct vaccine (CYD-TDV), commercially 3-dimensional structure. known as Dengvaxia®.

Figure 3: Construction of Dengvaxia® vaccine. The E and prM genes from all Table 1: Main findings of the Phase III clinical studies with CYD-TDV (Dengvaxia®) serotypes were incorporated into the yellow fever vaccine backbone. (image credit: Guy et al (2015) [8]) 77 Issue 12/2016 Issue 12/2016 78

investigators hypothesised that the Based on the interim results, the low efficacy in younger cohort could WHO recommended introducing be due to the ongoing development the vaccine in highly endemic of some vascular physiology such dengue countries. As of April 2016, as the capillary system in young the vaccine has been licensed in children. Secondly, the vaccine Mexico, Brazil and the Philippines. efficacy for DENV2, the predominant These successful authorisations will circulating serotype in Malaysia, allow collaboration with the national was disappointingly low (36.8% in authorities to conduct further Phase Asian countries and 50.2% in Latin IV studies to monitor any long-term About The American countries) even in the older adverse effects of the vaccine in cohort. Finally, the investigators also reality and the feasibility of the found much higher vaccine efficacy vaccination programme. in individuals who were seropositive at baseline, indicating previous exposure to dengue virus. Author

Dengvaxia® Dilemma in Malaysia

Upon completion of Dengvaxia®’s the University of Malaya and the Phase III clinical trials, the current Immediate Past Chairman of the Deputy Health Minister, Datuk Seri Asia-Pacific Dengue Vaccine to Hilmi Yahya announced that the Vaccination Steering Committee Nor Ilham Ainaa Muhsin vaccine will be made free for the rebutted the statement. His is currently in her final year of studying public by mid-2015 but the decision argument is that even if ineffective, DPhil in Molecular Genetics at University was reversed several months later. vaccines recipients will still benefit This is due to the fact that the overall from vaccination as Dengvaxia® of Oxford. She is a newbie in the scientific vaccine efficacy at 60% was not was shown to reduce hospitalisation research field but eager to put her molecular convincing for larger scale usage. and severe dengue by 80-90%. This Besides, Dengvaxia® was shown can save our public health sector science knowledge into translational studies, to be not as effective against the tremendous amount of money each which hopefully will benefit the country. most current prevalent serotype in year, as the economic burden of An adventurous person, she enjoys nature Malaysia, DENV2. dengue in Malaysia is approximately RM 360 million per year. the most and has plans to visit Malaysia’s Professor Emeritus Dato’ Dr. Lam wonderful islands and rainforests once she Sai Kit, an eminent virologist from submitted her thesis. She is also an avid runner. 79 Issue 12/2016 Issue 12/2016 80 References

[1] http://www.who.int/mediacentre/ T., Dietze, R., Hj Muhammad Ismail, factsheets/fs117/en/ H.I., Reynales, H., Limkittikul, K., Rivera-Medina, D.M. and Tran, H.N., [2] http://www.cdc.gov/dengue/ 2015. Efficacy and long-term safety epidemiology/ of a dengue vaccine in regions of endemic disease. New England [3] Encyclopedia of Entomology, Journal of Medicine, 373(13), Volume 4 by John L. Capinera pp.1195-1206.

[4] Halstead, S.Á., Nimmannitya, S. [8] Guy, B., Briand, O., Lang, J., and Cohen, S.N., 1970. Observations Saville, M. and Jackson, N., 2015. related to pathogenesis of dengue Development of the Sanofi Pasteur hemorrhagic fever. IV. Relation tetravalent dengue vaccine: One of disease severity to antibody more step forward. Vaccine, 33(50), response and virus recovered. pp.7100-7111. The Yale journal of biology and medicine, 42(5), p.311.

[5] Ng, L.C., Koo, C., Mudin, R.N.B., Amin, F.M., Lee, K.S. and Kheong, C.C., 2015. 2013 dengue outbreaks in Singapore and Malaysia caused by different viral strains. The American journal of tropical medicine and hygiene, 92(6), pp.1150-1155.

[6] Mellado-Sánchez, G., García- Machorro, J., Sandoval-Montes, C., Gutiérrez-Castañeda, B., Rojo- Domínguez, A., García-Cordero, J., Santos-Argumedo, L. and Cedillo- Barrón, L., 2010. A plasmid encoding parts of the dengue virus E and NS1 proteins induces an immune response in a mouse model. Archives of virology, 155(6), pp.847- 856.

[7] Hadinegoro, S.R., Arredondo- García, J.L., Capeding, M.R., Deseda, C., Chotpitayasunondh, 81 Issue 12/2016 Issue 12/2016 82

SciMy Ask Me Anything: Question 1: Have you always planned to transition from academic research to joining a biotech company, and then to founding your own startup? What were the factors that influenced you to take this path?

Not at all. It was always my interest and intention to be in academia. After my post-doctoral fellowship at Harvard, I was an Assistant Professor at Johns Hopkins in Baltimore, which was about a 45 minutes commute one-way to work each time. After six years and when our youngest was born, and with my husband Steve traveling a lot, the distance and time of getting to work became a consideration. So when I was recruited for the position of Director of Molecular Biology at a new start-up biotech company, I resisted until it became clear that the labs were two minutes away from my home!

Question 2: As a Malaysian scientist, have you been approached to contribute to, or help the local research community?

I just made it as a visiting Professor at the University of Malaya, my alma mater, in December 2015. During my last visit, I had the opportunity to lecture and meet and interact with the fabulous staff and students at the Faculty of Medicine. I am working on a nice collaboration with them now, linking with other institutions in the US and co-applying for grants with Malaysians in Malaysia. This is great and Dr. Betty Kim Lee Sim exciting! Founder of Protein Potential LLC & Executive Vice-President at Sanaria Inc. Question 3: Last year in the United States, pharmaceutical companies inflated the price of From the 1st to 13th of March 2015, Scientific Malaysian organised medication and vaccines way above the cost of making them. Considering that an Ask Me Anything (AMA) session on their online discussion the PfSPZ vaccine is targeted at developing countries where malaria is most platform with Dr. Betty Kim Lee Sim (@bkimleesim), Founder of prevalent, what precautionary steps would you be expected to take after it is Protein Potential LLC and Executive Vice President of Process approved for use? Development and Manufacturing at Sanaria Incorporated. Dr. Sim’s team at Sanaria Incorporated has developed the world’s first It is now estimated that it costs more than US$2.6 billion to bring a new drug or vaccine to market in 1 attenuated sporozoite malaria vaccine, the PfSPZ Vaccine, which the United States . In order to keep new drugs and vaccines coming, these costs must be recouped. is now in clinical trials in the United States, Europe, and Africa. In Having said that, Sanaria’s goal is to bring a PfSPZ vaccine to market as soon as possible and to use it to halt transmission of and eliminate malaria through mass vaccine administration campaigns. This particular, the PfSPZ Vaccine has also been shown to be 100% will only be possible if the vaccine is available at the lowest possible cost. We have already begun protective in two clinical trials. making agreements with African governments to assure this. That also means that the vaccine must be sold at a significant profit in the developed world for travelers to help fund the lowest possible Throughout this AMA session, registered members of Scientific cost in the developing world. Malaysian were given opportunities to post questions directly to Dr. Sim. Here, we summarise the discussion that took place during the session. 1http://csdd.tufts.edu/news/complete_story/pr_tufts_csdd_2014_cost_study 83 Issue 12/2016 Issue 12/2016 84

Question 4: There appears to be little vaccine research and development in Malaysia. How could Malaysia build capacity in terms of research Question 6: What do you think is the best way we can shape this pharmaceutical into vaccine research and development? What vaccines or diseases industry to enable less profitable cures and vaccines to be would you suggest to prioritise? researched and funded? These are critically important questions, but not so easy to address, as this will represent a tremendous shift in perspective and national commitment backed up by investment. The only way to shape anything is to move forward to achieve your goals. Singapore is probably a good model. Here are several suggestions, Crowdfunding is a good way to bring attention to these diseases, and to get some seed money. However, the amount of money required to bring a new drug or (i) the government needs to set up a funding mechanism with significant amount of funds vaccine to market (currently estimated to be $2.3 billion) cannot be raised through behind it to support this type of research (the Small Business Innovative Research [SBIR] crowdfunding. program in the United States is a good example),

(ii) the government needs to work with excellent Malaysian physician scientists to establish a first rate Phase I and then Phase II clinical trials center like he Jenner Institute in Oxford, United Kingdom (we work at such a center in Tanzania),

(iii) the team at this clinical trials center needs to be fully trained in GxP (GMP, etc.) and have the personnel (quality, regulatory, clinical, laboratory) and infrastructure (IT, laboratory, etc.) to run clinical trials at a level acceptable to the entire world, and

(iv) a few diseases such as dengue, which is now devastating in Malaysia, need to be focused on to get the enterprise off the ground. With such a commitment and resource, I think the Malaysian investment community, which has a large international presence in biotech, could be convinced to invest in Malaysian enterprises.

Question 5: Most clinical trials involving vaccines or drugs are very much based on western population. Studies have shown that several reasons (genetic predisposition, environmental factors, etc.) could contribute to the poor vaccines/drugs efficacy in non-western countries (i.e., developing countries). How can we address this issue to improve human health and to tackle diseases in the non-western countries?

We are quite mindful of these concerns, and in the context of the PfSPZ vaccine, we will soon be reporting on dramatic differences in immunological responses to immunisation with the exact same regimen of PfSPZ Vaccine in non-immune U.S. and semi-immune Dr Betty Sim Kim Lee pictured here with local children while working on Malian (West African) subjects. For these reasons, and because of the importance of malaria worldwide, we are testing our PfSPZ vaccines simultaneously in multiple ethnic clinical trials in Doneguebougou, Mali (Source: The Malay Mail Online, groups at multiple sites in the U.S., Germany, and six countries in Africa, and are working picture courtesy of Dr Sim) on getting studies going in Southeast Asia and South America. The answer is to assess products where they will be used. 85 Issue 12/2016 Issue 12/2016 86

Question 7: Biography: Have you ever felt that your gender played a role in your career progression, especially as you started during an earlier generation Dr. Betty Kim Lee Sim hails from Kota Bharu, Kelantan. Dr. Sim did her undergraduate (B.Sc., Honors, First Class) and graduate studies (M.Sc., Ph.D.) at the University of when there might have been more barriers for women? In relation to Malaya, Kuala Lumpur. After a postdoctoral fellowship in molecular biology at the Harvard that, how have you coped with juggling a career and a family? School of Public Health, she became a research assistant professor at the Johns Hopkins School of Public Health and worked with the Walter Reed Army Institute of Research in No. I have never felt that my gender inhibited my work or success in anyway. Perhaps their malaria program. it is an attitude. Yes, I did juggle my career and family, but in a happy way. I never distinguished my work from family life. Scientific discussions and discourse were In 2003, Dr. Sim founded Protein Potential LLC, a company focused on discovering, often at the dinner table. My sons met and got to know our collaborators and friends producing, and developing subunit recombinant vaccines, therapeutics, and diagnostics. Protein Potential’s core capabilities include the capacity to rapidly and efficiently take in science and medicine from all over the world. I brought my kids into the lab even newly discovered molecules through all steps required to initiate and conduct clinical when they were young when I had to tend to experiments! Gone are those days trials. Protein Potential’s platform technology includes recombineering foreign genes into when security and lab safety issues were non-existent. the attenuated Salmonella Typhi typhoid fever.

Dr. Sim is also Executive Vice President of Process Development and Manufacturing at Sanaria Inc., where she built the team and led the manufacturing effort for the PfSPZ Vaccine. Dr. Sim currently lives in Maryland, United States with her husband Dr. Stephen Question 8: L. Hoffman, the founder, CEO and Chief Scientific Officer of Sanaria. Their three sons are pursuing careers in law, medicine, and science. Any words for Malaysians that chose to have a career in scientific research? To find out more about Dr Sim, visit her Scientific Malaysian profile at http://www.scientificmalaysian.com/members/bkimleesim/ Research is a challenging career. But it selects for those who like the wild ride. Be bold and enjoy the ride!

Question 9: Roti canai or nasi lemak?

Roti canai :)

This interview has been edited for brevity and clarity. The original version of this interview can be accessed at:

http://www.scientificmalaysian.com/groups/general-research/forum/topic/ask-me- Dr Betty Sim Kim Lee at work in a laboratory in Equatorial Guinea anything-ama-dr-betty-kim-lee-sim/ (Source: The Malay Mail Online, with picture courtesy of Dr Sim) 87 Issue 12/2016 Issue 12/2016 88 50

• Interview with Hafizah Noor Isa, a Malaysian physicist involved in the groundbreaking detection of gravitational waves. GEms http://magazine.scientificmalaysian.com/life-as-a- scientist/interview-hafizah-noor-isa-gravitational- From waves/ Interested in joining the • Interview with Prof Dato Dr Mokhtar Saidin, a Professor and the Director of Centre for Global Scientific Malaysian team? Archaeological Research Malaysia in Universiti Our Sains Malaysia. http://magazine.scientificmalaysian.com/life-as-a- By being part of us, you will have the opportunity to enhance your skills and improve scientist/scimy-interview-professor-dato-dr-mokhtar- your CV by working flexibly and contributing remotely from wherever you are. Web saidin/ We are now seeking for enthusiastic and passionate volunteers to join our team for • Interview with Professor Philip Crosier, a the following positions: Professor of Molecular Medicine in the School of Articles Medical Sciences at the University of Auckland, New Zealand. His laboratory uses the zebrafish Web Developers model to investigate aspects of human diseases. http://magazine.scientificmalaysian.com/life-as- Role: Maintaining and adding new functionalities to our websites a-scientist/interview-prof-philip-crosier-university- Knowledge in Wordpress is essential auckland/ Magazine Illustrators or Designers • Interview (Part II) with Professor Mark Role: Producing original illustrations/photos or layout for the magazine Stoneking, a world-renowned geneticist in the Knowledge in Adobe InDesign or Photoshop is desirable field of human evolution and is part of the team who first introduced the concept of Mitochondrial Eve back in 1987. News Editors http://magazine.scientificmalaysian.com/life-as-a- Role: Writing short news reports on scientific research and developement scientist/scimy-interview-professor-mark-stoneking- news in Malaysia, to attend/report on scientific events/conferences part-ii/ Good writing and reporting skills are essential

• SciMy profile of the three winners of the Publicity Officers L’Oreal-UNESCO Women in Science fellowship Role: Promote awareness of Scientific Malaysian especially via social media, award. distributing SciMy digital magazine, liaising with relevant organisations http://magazine.scientificmalaysian.com/loreal- unesco-malaysia-for-women-in-science-2015- fellows-interview University Ambassadors Role: Promote awareness of Scientific Malaysian at • Event report: The 5th International Conference university campuses and research institutes locally for Young Chemists (ICYC 2015), organised by (Malaysia) or abroad. May involve organising events the School of Chemical Sciences of Universiti (such as talks or discussion forums) Sains Malaysia. http://www.scientificmalaysian.com/2016/01/12/ event-report-icyc-2015/ If you would like to contribute to Scientific Malaysian • Event report: Effective Science Communication in other ways not mentioned above, please do contact us - Workshop jointly organised by EURAXESS Links ASEAN and Young Scientists Network-Academy we are always looking forward to new ideas! of Sciences Malaysia (YSN-ASM). http://www.scientificmalaysian.com/2016/02/01/ event-report-effective-science-communication- Contact us: tea m@sc ientificma laysia n.com workshop/

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