 Hello, everybody, and welcome to the Ethics and Research and Biotechnology Consortia series. I am your host, Nsu Hyun. I am Director of Research Ethics and a faculty member in the Center for Bioethics at Harvard Medical School, and I'm also Professor of Bioethics at Case Western Reserve University. The goal of this speaker series is to expose bioethicists to some of the most important scientific research that is happening today, research that many of you may not have actually heard of, and that's just my honor to present to you Dr. Joseph Penninger. And before I do my introductions, I do want to just do a little bit of housekeeping. The Q&A box at the bottom of the screen is there for you along the way to pose your questions, which we'll get to in the discussion portion of the session. So please enter your questions there. If any problems arise, you can use the chat function to speak to any one of us. So thank you for joining us. I forgot to give that a little bit earlier. So getting back to the introduction for today, Dr. Joseph Penninger is an Austrian biomedical researcher who specializes in molecular immunology. Now, I don't think I've ever met somebody who has this many titles, but let me just go through some of his titles. He is the Director of Life Sciences Institute and Professor in the Department of Medical Genetics in the University of British Columbia. He is Professor of Genetics at the University of Vienna, and he is full professor in the Department of Immunology at the University of Toronto. But among his titles, I think my favorite one is the informal title he has. It's the nickname Mr. Ace II. Now, broadly speaking, Dr. Penninger works to develop new treatments for diseases by uncovering the fundamental biological principles that underlie development and disease. Now, to accomplish these goals, he develops and he deploys a broad range of in-detro and in-vivo tools that reveal the fundamental mechanisms involved in human disease. Now, most notably for decades, he has been doing groundbreaking work on the angiotensin converting enzyme 2 or Ace II for short. And in recent years, he's even developed a soluble version of Ace II for acute lung injury. So today he's with us to explain what we can learn from the Ace II cellular receptor, what we have learned in the past, what we are learning at present, and what we could learn in the future. So with that, I want to turn it over now to our speaker, Joseph. Welcome. And the floor is yours. Yes, thank you so much for having me and for this invitation. So I wanted to tell you a little bit about the ride we have been having for the last years to actually study Ace II. And so I want to take you from the discovery to, of course, to the COVID-19 pandemic and how this all came together and what we believe could be a possible solution for universal seroputics. Of course, for this ASIC seminar, it might be of relevance. There's the fourth wave now in Europe. So I'm Austrian, I work now in Vancouver in Canada. Yesterday there were 15,000 new cases in Austria, diagnosed cases for COVID-19, for better for the virus being infected with the virus, for a population of 8 million people. So that's quite significant. And today actually the government announced the fourth lockdown starting on Monday. And the other thing, and maybe we discuss this later, a compulsory vaccination. So as far as I know, that's actually the first country which mandates, legally mandates compulsory vaccination for SARS-CoV-2. So before I start having lived in Vienna and coming from Austria, of course, I have to always start with some paintings. And one of the grand painters of the 20th century was Oscar Kokoszka. And then Kokoszka was a young, unknown painter. You only had to pay the painting if you actually liked it. So when he painted Auguste Farrell, the family gave the painting back to Kokoszka. And so Kokoszka was quite disappointed. And then of course asked, so why don't you like this painting? I think it's actually a great painting. And they said, well, it doesn't really look like him because Kokoszka painted him with, as you can see here, with a hand hanging down, one of the eyelids hanging down. So Kokoszka painted Auguste Farrell having a stroke, which he actually didn't have. However, around a year later, he exactly had this stroke. So now we would call it the ischemic transient, a transient ischemic episode. So to anticipate what might happen in the future. But of course, this is for me what biomedical research should do. Use our technologies, the amazing technologies which have been developed in the last years by many people to fundamentally understand physiology, interaction with the environment, and of course disease. At all levels, from basic research, from translating basic research into medicines, working with patients, and of course, in Essex, to use this technology for the greater good and possibly anticipate what might happen in the future. And through this fundamental understanding and this consensus, we all agreed to come up with improving the state of the world. So to start this closure, so this is the funding agency which give me money and I will show you data from a company I started called the Pyron Biologics. So you can put it in the right context, so they tell you just to state my potential conflict of interest. This is my new playground. This is Vancouver, from where I'm actually talking to you. As you might know, we had really bad storms. So Vancouver is actually cut off via land roads from the rest of Canada. So all our supplies actually coming through the US now, which is interesting and the supermarkets actually have empty. So beside all this COVID-19, I think we should not forget climate change and the consequences of it. I'm actually part of European consortium studying infectious diseases because of climate change in Europe and I'm sure many other places on the planet. There are changed microenvironments which allowed, for instance, particular flies and mosquitoes to come into this microenvironment and actually bringing diseases into the communities, diseases we have not seen for hundreds of years. So this climate change is not just the water levels, my drys and the issue of CO2. So this is very strong consequences, how we interact with the world and of course in the world with lots of people living in urban spaces with change climate. So COVID-19 will not have been the last pandemic. So there's probably bound to be many more to come. So the story for me started actually when I was a young investigator in Toronto, working at the University of Toronto and I'm actually a trained immunologist. So we did some of the first knockout of myos and mapping of the immune systems which then led to cancer immunotherapies and eventually I got interested in genes which regulate the development of hearts. At this time, this was before CRISPR, before we could actually sequence humans. So we were just interested how if we could find genes which regulate the development of Drosophila flies, fruit flies. And here you can see some of the markers we used, Eve and Tinman and here the mutant. So and we then realized that actually Drosophila had two copies based on the screen, two copies of a gene which had been known for a long time called angiotensin converting enzyme. So post-op in my lab, my cracker actually works now for a company in Boston, cloned the second copy which is now called ACE2, angiotensin converting enzyme number two. So it's this dimeric protein, so this is the structure and it's evolutionary highly conserved. So we were involved in a recent study where you can find even an orthologous copy of ACE2 in bacteria. And this bacterial copy even has enzymatic activity and enzyme activity has this molecule which sticks out of the membrane. So it's a trans membrane protein and has this catalytic domain working as a carboxypeptidate clipping little peptides. So initially it was not really clear what ACE2 was doing and I should give proper credit to my group. Also we had the gene cloned was not the first publishing the sequence of the gene. So this credit goes to others but I'm a functional geneticist. So I was always interested what's the real function of the gene and larger networks in the living organism that's of course where knockout technologies and living animals can win. So we asked the question, what's actually the essential in vivo function of ACE2? So we created the first mutant animal, mutant knockout mouse using stem cell technologies to study this function. And this is what we saw. This is a heart study. This is echocardiography, heart beats in mice. This is our slang. So ACE2 plus Y means we actually mapped it to the ex-chromosome ACE2 in all the species we know also in human. This is basically a male mouse which is normal and this is a knockout mouse, a male knockout mouse that's by Y which is knockout. And as you can see in this particular mouse background we saw impaired heart function. And when we crossed it to the other mutants of the first ACE, then we saw total rescue. So basically what Mike had discovered is the critical negative regulator of the reigning angiotensin system to simplify. ACE makes a peptide with atamino acids which we call angiotensin 2. And this via two cheap rotin coupled receptors regulates some of the most fundamental physiological processes in our body, blood pressure, heart function, water, sodium reabsorption in the kidney. And thereby this system is involved in many, many diseases, hypertension. So millions of people actually receive ACE inhibitors or blockers of the 81 receptor of fibrotic kidney disease. So this is a strong driver of disease. And ACE 2 turns out to have exactly the opposite function that actually gets rid of angiotensin 2. So ACE makes angiotensin 2 and ACE 2 gets rid of angiotensin 2. And by doing so these two enzymes keep this critical system in our body. So that's the system after my lecture if you get up from your chair that's the reason why you might not faint because it regulates your blood pressure. So these two enzymes keep the system in balance. Then we realized that ACE 2 was strongly expressed in the lung and it didn't make any sense and our animals and mutant animals had normal lung structure, a normal lung function. So this didn't change normal homeostasis. And to study this a little further actually Yumi Koimai who is now a professor in Osaka in Japan developed probably the first one of the first intensive care units for mice. So it took us many years to set up systems where we could basically model acute lung injury in an intensive care setting more or less with the idea to dissect the molecular and cellular mechanisms which contribute to lung injury. So this was when we started this was around 2000, 2001. And when Yumi Ko plugged in our ACE 2 mutant animals into this essay here on top this is already a severe lung injury. So it's already bleeding into the lung. So we have this non-infectious model for lung injury which we developed and the ACE 2 now got mice developed very severe disease. So basically what Yumi Ko discovered is that ACE 2 protects from very severe lung failure. The blood vessels get leaky and this is why you see these blue colors here. So this is where we were and we were laboring away and then the first SARS virus came into the world. The Corona virus causing a very severe respiratory disease with around 10% legality calling called severe acute respiratory syndrome. I worked in Toronto at this time. So I just moved back to Europe. In summer, Toronto was actually the epicenter of the SARS outbreak outside of China. One of our students got sick, our hospital was quarantined and it was an interesting experience because at the end there were only 8,000 people as far as we know infected with the SARS Corona virus around 10% died. But this completely changed economies like Toronto. The film industry broke down for instance. We didn't know if you could send your kids to school again but the outbreak took from October 2002 to July 2003. So it took eight months to control this with only 8,000 cases. So the idea that we can really control COVID-19 and this new virus was this hundreds of millions of people infected was from the beginning foolish anyway. And then this paper came out from Mike Fassan at this time at Harvard looking for candidate receptors for the SARS Corona virus for the spike protein. And he came up to the surprise to me but not totally surprising because other Corona viruses use siblings of ACE2 for infection that ACE2 could be a candidate receptor for the SARS Corona virus infection. However, the question was is ACE2 actually essential because early on there were many other candidate receptors identified and so one never knows if this is actually important or it's just another receptor on the cell surface which allows the virus to enter. Since we had the only knockout mouse in the world at this time we send our mice to China they got infected with the SARS-CoV virus and in a normal mice, wild type mice in our slang we could recover virus in ACE2 knockout mice we couldn't. So this was the critical experiment to prove that in vivo in a respiratory virus setting of SARS-CoV-2 infections if there's no ACE2 there's no virus infection. So ACE2 is the essential in vivo receptor for the SARS-CoV-2 virus. And over the years in multiple papers we came up with this idea which is now in textbooks that basically the SARS-CoV-2 virus uses ACE2 to bind as an entry gate for infection. This also leads to ACE2 downregulation. So ACE2 is lost from the cell surface but ACE2 inactivates this angiotensin-2 peptide and there if there's a trigger of lung injury it infects us as non-infect just trigger it drives actually angiotensin and drives more severe disease. So basically the SARS virus became a dangerous virus because it does not just use ACE2 for entry into our body but it actually ACE2 is protecting the lung from more severe injury. So based on this and now again my conflict of interest we started this company basically the idea being like in diabetes there's not enough insulin therefore you give insulin back so lung failure there's not enough ACE2 therefore you give a soluble version of ACE2 back more or less that the SARS virus might have shown us a new medicine for ARDS, acute respiratory distress syndrome and lung failure which is actually happening in many diseases from sepsis to the Spanish flu to bioterrorism to anthrax to bird flu you name it. So this is where we were, we even did clinical studies and we're laboring away, we were in phase one and phase two clinical trials studying the system and dosing and of course safety measures and based on our work and from the introductions so we brought a lot of reviews on ACE2 and like one prices on ACE2 with this molecular mechanism of infection and then of course everybody said so it's beautiful work you did but who cares? This work on SARS infection on ACE2 is totally irrelevant because there's no SARS virus anymore. So it was a beautiful basic science work without any implications until of course this new virus, a sibling appeared SARS-CoV-2 causing this unprecedented panoramic virus induced disease 2019. Based on the sequence it became very, very rapidly clear that ACE2 must have also an important function and this advances in science from nanoparticles to cryo electron microscopy. This is actually a structure of the spike protein of SARS-CoV-2 and here in green is ACE2 so this is not our work but was many people very rapidly showed that spike can also bind to ACE2 from the SARS-CoV-2 virus. So the question then was since we had all this background and had been working on the system for 20 years already and as I said cloned ACE2 and developed the soluble version for already being in the clinic could we use the soluble version to block the SARS-CoV-2 infection? Again with the idea this is a critical receptor then this should actually work and to remind you again so SARS-CoV and the SARS-CoV-2 virus would utilize ACE2 spike binds to ACE2 and this is the signal for the virus to infect the cells and at the same time this would actually to ACE2 down-regulation internalization inside the cell the virus does what the virus does co-ops the machineries of the cells innate and adaptive immunity get turned on and of course many other things happen causing diseases we call SARS and COVID-19 and this was the idea of a soluble version of ACE2 acting like a molecular decoy like a sponge blocking spike to bind to the membrane bound version of ACE2 and of course by blocking there would be less virus getting into the cell and there should be improved disease so mind you every single vaccine which is in development we have been approved actually works on that principle to block make antibodies of course they also T cells but to make neutralizing antibodies which bind to spike so spike cannot bind to ACE2 anymore and by doing so can block the infection so nearly all approved medicines for instance the Regeneron cocktail Donald Trump got when he got sick based on this principle to block spike binding to ACE2 so we know this principle is real and has been proven now in basically everybody who has been vaccinated if they develop neutralizing antibody because this is also how we measure this so this molecular principle and ACE2 has gone from who cares anyway to probably the most studied a molecule human molecule on this planet because of COVID-19 so to study this we hooked up with the group in Sweden to do infections this is the virus we worked with from isolated from the first Swedish patients so we took this virus infected cells we called Vero E6 cells it's like the workhorse for the virology we do and then of course I asked the question if a soluble version of ACE2 could inhibit this infection and we published this last year in cell and basically we could indeed show it as one would expect if this is important and reduce the virus load by a factor of 1000 to 5000 times so the other question which was important is and now we know this is real but initially COVID was a respiratory disease this involvement from other tissues like the blood vessels and people died of clotting and blood vessels involvement of the heart of the kidney but it was more or less secondary so it's a respiratory infection but of course we knew that ACE2 is not just expressed in the nose and in the lung cells but it's on the blood vessels it's in the heart so we had published and other people have published many papers it's in the central nervous system ACE2 expression changes with age and gender we mapped it to the X chromosome being its critical regulator of blood pressure and heart function of physiology of course it changes with cardiovascular disease diabetes and smoking and we also mapped ACE2 on the surface of gut epithelium here and there were cases coming out that actually there's a viral RNA in the stool and there's some people develop diarrhea and we mapped ACE2 into the proximal tubules in the kidney so we knew ACE2 was expressed in many of these tissues and so the question was maybe it's not just a respiratory infection but because ACE2 is expressed in many tissues it can spill out and of course infect other cells which express ACE2 as a surface receptor to do this we went into tissue engineering this was Nuriya Montserrat engineered little human kidneys and here in single cell analyzes you can tell the very complex different cell types in there and ACE2 is also expressed exactly at the same place in the proximal tubules where you would see it in humans and in animals so we actually made this kidney organ which sent them to Stockholm for infection and with the virus and indeed we could infect them and the soluble version of ACE2 could reduce this but the other tissue I was interested personally was actually blood vessels some years ago we developed a system out of stem cells to grow perfect human vascular germ with lumen endothelium and parasites and base of membrane and of course the virus needs to spread somehow and of course needs to spread through the blood vessels so we made a vascular organ it sent them to Stockholm and indeed they could be infected there's viral progeny so it's not just infection but there's active infection creating new virus and again in a self-fulfilling experiment if ACE2 is important as an entry receptor can be blocked with the soluble version of ACE2 so to bring this all together of course there are many other things which happen in COVID-19 and in SARS-CoV-2 infections there's ACE2 on the nose, epishelium in our throat this is where the virus lands and most people might not even realize this some people get common cold and that's about it if the virus gains access to the lung ACE2 is expressed in very deep lung cells so this is why COVID patient get this very typical deep pneumonia you can even hear it so there's this COVID cough because of course the places of infection and pneumonia and the lung are different like from a flu infection and of course there's damage now for pneumonia there's tissue damage cell spilling the virus can be produced and then the virus would spill out through the blood vessels the shoulder that can be infected not all of them but certain some subtypes and then of course can spread in tissues which have ACE2 into the heart into the kidney, into the liver, into the gut so ACE2 can explain a lot the first intracite the particular way of pneumonia and of course the spreading in other tissues so COVID-19 is clearly not just a respiratory disease it starts there but in severe cases it's a multi-organ involvement and ACE2 can explain some of the distributions of disease of course there are many other things happening out immunity, immune system changes coagulation changes and so on so we also ran the phase 2 clinical trial with this soluble ACE2 the reason being because it reduces the virus infection as I showed you not just from our data but from data from basically everybody who does this and secondly the basic function of ACE2 is actually to protect many organs the heart, the lung, the kidney, the liver, the vasculature from tissue damage so the phase 2 clinical trial is finished with actually very few patients so also something maybe to discuss that actually the Essex and the dynamics of drug development for COVID-19 so honestly despite all this outpouring we work together this was not optimal what the WHO did was also in my opinion not really optimal so this actually blocked a lot of really good drug developments so we didn't have enough patients at the end of the day we had some tendencies I think all we learned not just us but basically everybody who did this clinical trials with antibodies and so on is you have to treat as early as possible and then you see a best effect this is now also part of the connex platform trial in the US where various modulators of the rehinensia-tensin system including our ACE2 is being tested in patients and of course there's the issue of long-term effects of COVID-19 there's certainly out immunity which contributes to this and we have published on that and of course many other people but ACE2 in its function of course could be also a very critical regulator to do this because if every time we take away ACE2 in our animal models diseases get worse in multiple tissues and every time we get more ACE2 into the system we can alleviate such diseases so it's still unclear what's the mechanisms and where the long-hauling will lead but it's clear it might become a real problem in the future and already is so this is where we are now in this world and science has amazingly contributed to rapid vaccine development amazing RNA technologies and other particular technologies naked spike just to remind an overvax just applied for approval and of course we started to vaccinate in the pandemic and exactly it happened what everybody would predict would happen the virus mutates as it always does and of course has to adapt to local immunity against the virus so variants developed just normal viral evolution variants of concern and variants of interest so I can tell you in Austria now to 15,000 cases a day probably also in Germany for Austria no for sure because one of my former students is not sequencing all the cases it's 100% delta variant so the initial variants more or less disappeared and now dominant variants happened and of course we have these cocktails of antibodies but the variants and the hundreds of papers now with this shading of gray on the effects some of them escape immunity at least in part and also some of the antibody cocktails which had been approved don't work anymore because of this escape as we would expect and there's nothing really unusual about this so the question then really is can we develop actually universal pan-sask of two variants therapies because this variant occurred there are many more variants out there and because of this evolutionary pressures of vaccination and of course of therapeutics there will be more variants in the future so I think we can all agree to this so could we actually develop universal strategies against all the variants and nature actually gave us this strategy already and this is ACE2 because the virus might mutate to escape a particular specific antibody but it cannot mutate to escape binding to ACE2 because if it mutates out of binding of ACE2 then there will be a different disease then the only way is you can find another receptor but the disease we call COVID-19 will disappear so this is a given in evolutionary terms so nature basically gave us an answer to a potential universal therapy of course you can also go for the viral proteins or blocking like Rendezvous does the viral replication but as we know from HIV studies there might be mutants occur so is this actually real and to do this we hooked up actually with colleagues at the National Cancer Institute NIH and tested the Alpha and Beta variant and the reference strain so this is the first Wuhan strain the first Swedish strain we got but this was from our first paper APN01 is the soluble version which is in the clinic of ACE2 and in our first paper and cell we published that around 25 micrograms of soluble ACE2 lead to inhibition of the virus by around 40% if we do the same with Beta and Alpha we see this amazing inhibition which makes sense because if one does actually affinity measurements then the much higher affinity of the mutants to ACE2 therefore ACE2 can actually block better so how about the Delta variants we also blocked this and this is the data we got three weeks ago this is the same as I showed you before so soluble ACE2 blocks efficiently Alpha and Beta and Delta even at those is a 5 microgram here where we see hardly any inhibition of the reference Wuhan strain we see nearly 100% inhibition of Delta in this cell line and other cell lines and again it does make a lot of sense Delta has shows much higher affinity and also Beta Alpha to ACE2 and therefore ACE2 becomes a super molecular inhibitor like super specific and super high affinity antibodies to block this this is 0.1 nanomolar of activity so it's very strong inhibitor activity so if one proposes this universal therapy then we better know if ACE2 is actually the essential receptor and to my amazement this was never really addressed and there are lots of papers in major journals in cell and science and nature coming up with candidate second receptors we don't need ACE2 for instance Neuropelin 1 so the question was really is ACE2 actually the real receptor or could it be just another one and who cares we block and actually vaccinate against ACE2 but there could be another intracite and this is what's the real problem but was really difficult to study this you know how do you actually study this in a real respiratory setting and to do this with Sylvia Knapet in Vienna she developed a new mouse adapted SARS-CoV-2 virus so basically in fact a mouse and passage for 16 passages and she actually came up with the virus which is causing very severe COVID-19 pneumonia in animals and in a particular mouse background they're all dead after five days if you give them a high dose of the virus the body temperature change the weight changes this viral load so all it took is actually there are two mutations here in spike which allow now SARS-CoV-2 spike to bind to mouse ACE2 you know a spike of SARS-CoV-2 is not only specific for humans it can infect lions and tigers and ferrets and many other species but not mouse or rat but with these two mutations you can make a very effective virus and bulb seed mice die and actually black six mice get transient severe pneumonia and then recover so here you can actually see the virus in the lung so doing this we could actually finally ask the question is ACE2 actually critical for a respiratory infection so we infected our ACE2 now got mice with the SARS-CoV-2 and normal mice get the severe infection they actually die the temperature changes body weight changes this infection ACE2 knockout mice have nothing so now we know ACE2 is also absolutely essential for a respiratory infection with the SARS-CoV-2 virus so this strain is actually called MAV-16 for mouse-adapted SARS virus made in Vienna with 16 passages if you've wondered where the name comes from so could there be other therapies universal therapies of course there could be and of course we have to look for them and one of them is spike is heavily glycosylated ACE2 so sugars on the protein backbone could and should contribute to the infection so VEV and many others who actually did this now marked all the sugar residues on spike so spike is 22 a glycosylation epitope which are highly conserved in evolution and then we cloned actually the largest the sugar binding protein library molecules which are called lectin in the world to probe which one of this protein sugar binding glycosylation binding proteins would actually bind to the virus to make it short we actually came up with two of them and other people as I said working on this intensively into amazing research one of them is clack 4G and the other one is CD2 online so these are mouse lectins and also human lectins which we proved later to bind to this glycosylation epitopes of spike so this is actually what we do here is the spike and this is how the lectins actually attach so this actually allows us to look in real time for receptor spike interactions at the single molecule resolution level and this is actually how it looks you can actually see a spike protein dancing with this lectin binding and we're doing now the same with ACE2 and delta variants and actually really interesting looking at the single molecular resolution level we can at least in part explain now but it's work from somebody else I shouldn't talk about this in detail in part explained by delta became so infectious and how it actually attaches much better to ACE2 and what happens and at this single molecular level I just love the movie because it's like a molecular dance of a primary spike with lectins so this is how we mapped it exactly this is ACE2 and this is CLEG4G actually CLEG4G binds to a sugar which is straight at the interface between ACE2 and spike CD2 and 9 binds to sugar which is actually on the side of spike both of them can efficiently block infection how binding on the side blocks infection we don't know probably some steric hindrance so to put this all together this spike in the receptor binding domain and this residue has this like the arrow of a Greek god has this very long glycosylation site actually touching down on ACE2 and this is where this CLEG4G binds and we also mapped that this this is not just protein protein interactions between spike and ACE2 but also that sugars and this glycosylation site heavily contribute so one could also target this of course because if you target this sugar here then you can also block binding of spike to ACE2 which is actually conserved and we have not found any mutant of variant of concern which actually has lost the sugar I think we actually did some studies this probably seems essential to make even spike so that's why they cannot lose it and the problem with the lectins is compared to ACE2 problem is in relative terms is so ACE2 blocks of nanomolarity affinity and then much higher even this lectins because of the setup and how they work at the molecular level you need thousand times more of this lectins to work so of course one can engineer to improve them so I'm telling you fast what we actually doing with our models we have mouse models and human tissue engineered models we all know comorbidities contribute to more severe Covid diabetes hypertension so we have started now to develop actually organoids with comorbidities with diabetes so Nuria Montserrat developed this model for diabetic kidney organ which is really interesting so sugar and indeed if one does this there's more SARS-CoV-2 infections so we can model now in vitro in a human engineered kidney diabetic changes and this diabetic changes allow for more infection of the virus so this also allowed us to address the question what I showed you in the mouse ACE2 is essential for infection of this kidney organoid so we made knockout organoids and Nuria did in Barcelona here are four different clones wild type clones here SARS-CoV-2 infection they can get infected efficiently and when ACE2 is knocked out there's zero infection so ACE2 again even in the presence of neuropyline another described candidate receptors is essential for the virus infection no ACE2 no infection in this kidney organoid and does this also happen in diabetic conditions so this is diabetic conditions and in normal organoids there's infection here's the NP from the virus nuclear proteins so productive infection and if ACE2 is knocked out there is nothing I should also mention there's similar data in gastric organoids which Nuria did and it's not published yet and there were two other papers a group from Arizona the knocked out ACE2 in cardiomyocytes derived from stem cells no infection and Hans Clavers group knocked out ACE2 in gut organoids which can also be infected no ACE2 no infection so I think we're reasonably confident now using human engineered tissues from stem cells and also mouse models that ACE2 again is the absolute essential receptor and can be of course test therapeutics using our new mouse model after all to test therapeutics in organoids where human cells is great but the dynamics of a real infection one cannot really use and the mouse models people have been using a very artificial because the most model people uses overexpression of human ACE2 but in tissues where which you normally never see ACE2 expression of this my style of massive brain inflammation and virus explosion in the brain because the overexpress ACE2 in neurons and so we believe of course the other models are not just us that we need to generate better models to study this and of course our mouse adapted virus allowed us to do this so and to get back to this universal therapies could we actually block the infection if you have a inhalation of ACE2 so the mice got infected and then they got intranasal very common and mouse soluble ACE2 because this virus binds actually to mouse ACE2 and we could totally block the infection and the longer you wait after the first infection the less protection you get so it makes total sense this interplay you have to treat early even this respiratory intervention and of course we wanted to know if this could also work with the drug which is in clinical development and this virus which is mouse adapted still binds to human ACE2 so we could actually this clinical grade recombinant human ACE2 we could use infected the mice got the mice got the respiratory infection and then they got ACE2 intranasal to block the virus and again we saw total protection doing this early enough and total protection from death of course other people do this with antibodies and again and this is my last slide based on the molecular principle the ACE2 is the essential receptor for the SARS-CoV-2 virus which is the principle where all our vaccines are based on at least to block this infection and the dynamics of viral evolution in this context that we are vaccinating the globe now against this there will be variants but none of the variants can escape ACE2 binding so based on all of this information from our lab and of course hundreds of other laboratories where this is always the same and reproducible and this is basically the heart epidemic of the virus infecting us we believe it's possible to develop a universal pan-COVID SARS-CoV-2 infection therapeutics and we have learned we have to do this as fast as possible the earlier go the better so this also experience from antibody studies also from the new drug switch out there from worker and Pfizer blocking other pathways after the virus infected and actually believe this principle should and must be combined learning from HIV infection blocking entry blocking something inside the cells but if you go early in treatment of course you have to have a treatment which is feasible which can be used in millions of people can be used in Africa in other places and more or less the treatments we have and the severe as IV the antibodies intravenous one needs to develop a form of application which can be done fast is cheap and can be used in lots of people so that's why we actually developing this inhalable form of ACE2 and this is now in phase 1 clinical trials in Europe so in DOC studies we showed it on toxicity so this is now so we actually being sent back from the system on drug development to do phase 1 again also we have already this data at least for intravenous infection so I can actually understand who knows what this might do in you know if you inhale ACE2 if there's some allergic reaction and so on so and big thank you to our colleagues at NIH and NIAID who helping us to to set this up Robert Schumacher and Michael Holbrock who helped us to develop this and of course we hope now that this can proceed very fast here I could make because it's ASIC seminar I think what has happened and what one has to consider very carefully is now we have these vaccines but as we all know these vaccines the vaccinate against the virus getting into the blood and of course protect against severe disease but they don't protect against the infection at least not efficiently in the respiratory system so we need better vaccines but of course now vaccines are approved how do you actually develop a better vaccine in the area where other vaccines are approved so is this ASIC or even possible can we do this should we do this but the same for our ACE2 how can we actually test this if already the antibody is there Merck and Pfizer got the proof do we actually even need this I strongly believe we need this of course I'm biased having discovered the system in the first place but what do we really need this and if we need this if we have a consensus we need this how can we actually develop this effectively and I'm saying this because I learned this the hard way every drug which has been approved or is in development in live stage development is from the big boys so not a single small biotech has managed to develop this and there are many reasons for this and one of the reasons is just to have the manpower and all the money and so the question really is for systems like this in a pandemic like this so what's actually the role of government to WHO to step in and say we want to develop other promising drug candidates because they're so important and we're actually financing this so to be frank we are very delayed with our development because we just cannot find the money to do it and I really don't understand it because I hope you agree with me this makes complete sense and despite making complete sense we still cannot find enough money to actually move ahead at the speed which would be necessary but that's happy to discuss this and with this I end here and shank the people who did the work so Mike Racker who cloned AIS2 in my lab again we were not the first publishing the sequence we made the first knock out mice we had the sequence in our computers but we wanted to know the function but all the credit to the others Yumiko KGR developed this intensive care units where we could define the function in lung failure and of course show it's the essential receptor in Viva for the SARS virus Nuri Ali Vanessa is our team and many more which use tissue engineering to study SARS-CoV-2 infections of course many many people do this lab with very sophisticated models Alex Tufali is the clinician we work with it's always good to know what we actually do what's the real clinical issue for what reason we're actually doing all of this so he allowed me actually to go to the intensive care unit for COVID patients which was the real eye opener to see this not just being so attic and do all these models but actually see the real patients Stefan and David did the lectin work again my conflict of interest this company is doing the AIS2 studies are there actually many other companies who do the same thing obviously based on the idea and the data I think there are at least 10 companies in China now which developing AIS2 for COVID-19 and multiple efforts in the US and other places and Sylvia and her team developed a mouse adapted virus and many many more who helped us and with this thank you so much for listening well thank you so much that was absolutely fascinating we're getting many questions coming in and I'm going to group them into categories of topics but before I do that I was with you at a meeting in Barcelona in early 2020 when it looked like you were getting the first idea that that AIS2 was a major player for the COVID-19 virus and I remember at that time it was very exciting you were keen to get in contact with the WHO can you tell me a little bit about what happened there did you contact them were they receptive to take you through that period in early 2020 we contacted them they were not receptive they didn't even write back to us I think the first priority was to repurpose drugs which already out there this is where the whole hydroxychloroquine stuff came from even McTin so they were not responsive whatsoever it's our experience okay well then let me turn to some questions we have several questions that are kind of about some of the logistics and some of the more technical angles so I want to address some of those first and then we'll get into some of the broader ethical issues so some people were wondering could you explain a little bit more why you think COVID-19 affects different people differently I mean it's because different people express different levels of AIS2 younger people you've touched a little bit on people with morbidities but what's fascinating about your talk is you're explaining some underlying mechanisms that kind of start to make sense of what we've been hearing about the disease experience and the different interventions people have tried so could you speak a little bit about the variability of people's you know conductions yes so the data out there that for instance children have less AIS2 expression in the skulls and the nose which might be one of the reasons that we're not much infected probably with Delta we see a lot of infections in kids because you need much less virus particles to get infections so you can have less AIS2 so this makes a lot of sense there's this gender differences being on the X chromosome of course you know by then one kid gets sick and the other one not and of course for adults too I think there's still a million dollar question out there and of course for the clinicians this is critical how do you stratify somebody who might get more sick compared to somebody else for the whole system this is essential actually what they found really interesting people mapped on human chromosomes some some susceptibility loci get the more severe the less severe and one of the genes was just identified last week published in Nature Genetics from the British group so turns out this might be actually a regulator for recycling of AIS2 so this was actually not the locus so it's clearly to control severity of disease but it's everybody expected it's immune regulator but it's probably a regulator of AIS2 expression which is really interesting another question what will the effect of soluble AIS2 between vaccinated and non-vaccinated people is there a difference we don't know we don't know we are actually I'm on some expert committees about vaccination you know there's some cases luckily not so many of myocarditis happening and the more spike you express the more myocarditis cases you see mostly young males so Moderna having the most because of just the highest expression of the spike if this is somehow related to actually spike binding to AIS2 and deregulating some system we don't know that's a very important question great so another question from Rebecca Coffey this is incredible work I'm interested in whether we have been able to see the effects of soluble AIS2 after a period of time in terms of the required balance function of these receptors in the body I mean the data that AIS2 gets shared in the real infection so you see actually soluble AIS2 how this relates to disease really we don't know which has no membrane bound AIS2 is the critical receptor protects tissues and if we do a lot of soluble AIS2 we can also protect the tissues let's see let's see how this relates so you made an analogy that was very interesting between like insulin for diabetes and soluble AIS2 is there a point where too much soluble AIS2 becomes bad for you like too much insulin and bad for you like how would you know what the tolerable dose would be yeah we did actually the study I mean one worry of course was you know if we do soluble AIS2 regulating blood pressure you know people would actually drop because of blood pressure changes so that's why we did the phase one to our amazement we didn't see anything and also now in the clinical studies the safety profile of blood pressure profile and so it was actually really acceptable and reasonable so and we really went up to high doses of phase two we don't obviously if we overdo it there might be something but we have not seen much at least the dose we used for the clinical trials just a couple more technical questions how do you administer soluble AIS2 in a targeted way so for the phase two B trial we did it intravenous twice a day because the half life is around 12 hours so for seven days again you know we have not published the paper yet but the data we see tendencies for improvement but we did not reach the primary end point because we didn't have enough patients and I think we just like all the antibody studies people did we were just too late we need to go earlier and then we also realized actually I talked to the CEO of Horsch who I know quite well and he said we know antibodies work if you use them as early as possible but people really don't use them because of intravenous application right now you have a meeting with 200 people somebody is coughing at everybody so what do you actually do then now of course send 200 people for IV infusions which might work at Boston at Harvard Medical School but in normal life somewhere else might not work but maybe in normal life it could work because it's much easier that's why we do this and others are going for this direction so if one goes early you need a form which is easy applicable and feasible to actually use inhalation or all pills but FISA and work at one okay so let's go to some questions now that are a little bit more social from Kelsey Berry how has a sudden global interest in ACE2 in light of COVID-19 impacted your labs research portfolio for example has there been a dislocation of your other research efforts in response and our novel competition for grants funding or other streams of research that have made it more difficult to plan and execute your work how do you think about situating your work in this very active area we had actually made it more difficult for many other projects I'm running the largest life sciences institute at the Canadian University here in Vancouver we had to shut down the institute minimal work many other places of course had the same experience some places told me they had to actually kill mice they had been working on for years so this had a massive impact for many people on the basic research I mean here we have people who do for many years for 20 years they went out to the oceans to make samples and they were not allowed to go there anymore so long term research projects were disrupted and of course because of this and the whole funding went into COVID it seemed to me at least everybody on the planet all of a sudden did COVID-19 studies so this became ultra competitive for us we had been working and laboring away for years and had our first paper and then we were basically completely blown out of the water labs with 50 post-docs and everybody doing the same thing so we and I'm reasonably competitive but we had just totally blown out of the water and we could not compete anymore and of course now also people who work on stem cells the supply chains have changed so we had to stop lots of our experiments because these global supply chains from Piper tips to you probably all have the experience of working stem cells you know we have to wait for months and yes this was a massive disruption and one thing I always did here to give messages to everybody working in the institute that all research is important not just in the short term we all have to work on COVID because of course lots of other research which has critical importance and we should not forget about this we tried to make sure that everybody got the message that they're not left behind to work on warms or drosophila and it's also yeah and I don't know if I should say there's one reason why we actually made this mouse adapted virus so the mouse adapted virus as people did this so I wrote to these people in the US and they didn't give me the virus we didn't even get the response so they just use it for themselves and so you know there was also this whole public notion we all worked together for the greater good did not really happen at least at some level let me follow up on some of this this is really interesting so another question what does responsible research and publication practice look like in the context of this kind of heightened desperation and demand for knowledge can you talk about what you think are responsible research and publication practices in light of some of the things you've said about people not wanting to share resources yeah it's not even this gosh every journal preliminary data were published in some of the top journals and without doing right controls I can tell you in one of the top journals to publish the study that load those of solid ways to enhance these instructions nobody can reproduce this we brought to the journal and they're not really willing to take this out from the literature so I think there's a very complex answer at various levels from the gold rush mentality and lots of people jumping in and doing fast experiments without knowing the systems and coming up with all these great ideas because if you publish in a journal you need to have something novel so if you do actually solid work and say this is the key and we knew it 20 years ago so you know this dynamics of everything needs to be new I mean seriously how much can be really new I mean at the end of the day and so I think there are lots of papers published which should never have been published and now somehow the journals are very hesitant to to take this out of the literature I mean for ACE2 I know because I followed lots of papers on you know ACE2 there's so much ACE2 here and the next paper is it's not there and then you realize you know they use different antibodies and different reagents and but as soon as you mentioned ACE2 and it's different from what people published you had a good paper so yes this was anyway but this was the dynamics which happened Right, but you did talk in your presentation about your collaborations you have with Nora Montserrat who is an organoid friend so you have actually have been successful in forming collaborations and moving the work forward how did those collaborations you know start and speak more to that I mean so on the one hand you said that things are competitive and people don't want to share but you actually have been pretty successful in the last year of forming collaborations I don't just want to say negative there are lots of people so the whole thing happened I was actually in a meeting in Barcelona and then the sequence of the SARS-CoV-2 virus came out and then I realized immediately ACE2 must be involved and then I thought let's use engineered tissues to study this and actually this moment Nuriya who I didn't know was giving a lecture on kidney organoids where I ran up to her after the lecture and said why don't we combine forces and just knowing ACE2 must be expressed in the kidney organoids and she smiled at me and said let's go there are also very good other examples and this is the group in Stockholm we had been working and collaborating for a long time and so I called them and within two hours we had our consortium together and everybody was really open and shared things so yes that worked really well at least so I didn't want to be totally negative and I'm sure there are many many other examples of people successfully working together sure so before we move on to other questions about pricing and also funding for the research a few more technical questions came in so how would you localize the delivery of soluble ACE2 for lung delivery would it be through the nose or mouth so initially you talked about treating people with acute lung failure so for the acute lung failure we actually initially tried IV so this is how we developed it so the phase 1 and phase 2 trials were IV now we really want to go for inhalation studies so which was aerosolized so it's actually aerosols at the size which go deep down into the lung because one could also design aerosols at the particle size which gets stuck in the nose and the throat I think this should be also done and really go back with this local application for lung failure indication so I think this this has a good future beyond at least a future which should be tested based on all the data available beyond COVID for many other lung failures I just here for instance in Germany a friend of mine the the largest German children hospital so they don't see many children with COVID-19 but they see the stations and intensive care units are full with kids with respiratory syncytia virus because of the lockdown there was one year there were basically no infection and other exploding cases were very severe pneumonia and who knows maybe we can also use it for there to block some of the mechanisms of driving more severe lung disease so I think this goes beyond SARS-CoV-2 at least should be tested beyond SARS-CoV-2 yeah okay so a couple more technical questions and I want to get into funding and other broader issues so will soluble ACE2 be potentially useful for other diseases other than SARS and COVID yes as I just pointed out other respiratory diseases and we know from hundreds of papers the ACE2 protects from diabetic nephropathy cardiovascular damage liver lung fibrosis and of course they need systemic application so our application for the moment is IV 12 hours half-life so for more chronic disease I think one should define and develop a form of ACE2 which is more stable, has longer half-life you can give every two weeks as an injection and then test it yes there's life beyond COVID yeah yeah so on this front then have you noticed any changes in the half-life on different entry points well the only entry point that we really tested in humans so far is really IV so now we're in phase one in inhalation so I cannot answer this question but it would be interesting to see sub-Q also because on pharmacodynamic analysis slow release or slow infusion then you probably need much less protein to have effects and longer lasting so I think even to use the current form we have to prolong the half-life in vivo okay and one more technical question would you clarify why a universal therapeutic strategy is preferable to a variety of therapeutic strategies that each address their own dimension of the SARS-CoV-2 infection because there will be as we know there are many variants there will be new variants as well and we know this escape the vaccines at least in part they will escape the next antibody cocktail of course what will happen from the dynamics there will be the delta vaccine they're already working on this and of course the big companies will make the next antibody blocking delta and of course this will also happen but I think when the next variant hits then something like soluble ACE2 makes sense basically preparedness for the next variant but there are also many other coronaviruses out there which have not jumped to humans yet but can also use ACE2 so the strategy could also work so yes so this is of course not the only solution but I think in the whole context of improved vaccines new antibodies against variants in this times of hiatus where we don't have to be finishing then this could be quite useful because it will mostly always work okay so let's get to broader issues about funding this is a question from myokichan regarding the ethics of new drug development in a pandemic if governments or WHO were to help fund development do you think companies would be willing to give up patents it's an interesting probably not I don't know I mean we're seeing it what's happening probably not just a protective of the technologies okay well let's talk more about fair access and pricing so another question by Kelsey Berry what kinds of commitments to fair access and pricing would you personally consider important to make in the course of further developing your research into a significant intervention oh yes absolutely I mean at the moment I have to be frank because of production it's not our setup is not cheap so you know this to have really wide access one would actually have to and we unfortunately never had the opportunity to get together with people who can actually produce this in much larger scale much cheaper to make it more accessible to many many more people so I think it's very very critical so this also I learned you know you can have the best idea on the planet to heal and treat something but the production the accessibility the pricing will be very important you know for rare diseases of course you can ask for quite the price for chronic diseases but for something like this you know if we talk about maybe treating people in Indonesia in Africa and other places one has to have a reasonable pricing and I think the only way to do this is that the government agencies step in to actually support some of this development there's no other way to do this at least I cannot see it do you think that there are long-term impacts on the practice of science from this experience with COVID and this major upheaval of public health emergency do you think there are long-term impacts on science? Yes it will the first impact is that we know as a community of kindred spirits trying to improve things if we really get together we can come up with some solutions it might take it always takes longer than we think but I mean at the end of the day how fast the development of the COVID interaction was spectacular spectacular success of science which is of course based on science which was developed 20 short years ago actually my neighbor here is the guy who developed the nanoparticles he works on this for 40 years hardly anybody mentions him but there would be no vaccine of modern bio intact without his work 40 years ago so I think also the fundamental sciences will be more appreciated realizing it's very important to support this but this might help one day and it's totally ignored but tomorrow it might be actually very critical so and I think the positive message is if the the new technologies and the global brain at all levels from basic understanding to translating it in companies and to the patients I think if this global brain and this global knowledge I think taught us that if we really willing we also willing to provide from governments to public to investors enough money there are some things we can solve which were always somebody worked here and somebody else and everybody was competitive so yeah I think we should really fundamentally rethink what we're actually doing and I really think I don't know if a step people on the toes so the business models of NIH granting public granting the Canadian CHR I think it's a broken business model the modern world doesn't work like this anymore we should really come up with proposing a grant and you get killed and only 10% gets funded and everybody gets frustrated it's such a base of energy and so I think we have to come up with really new business models but here they're kind of developing I think the MIT review actually jumped the gun announcing this new initiative I think Altos so there's apparently private investors rich American private investors might be willing to spend billions of dollars to address a particular issue so let's see and this of course will change the dynamics of funding research if more and more of these initiatives happen they might get out of the hands of traditional governments what governments support and push and I think this also will be an interesting exercise you know who owns knowledge I mean but if the American US government supports it the knowledge will be to large extent in the public domain but if private investors do the same so who actually owns this to what end do we do the research so I think this will be really intriguing questions for all of us Joseph do you try to support responsible research in this area by maybe participating in peer review or speaking publicly you know do you sort of get involved a little bit more in trying to change the mindset and how people think about research oh yeah I always did and I continued to do I give lots of public lectures to exactly do this and after I've worked for many years in Austria when I moved there 2003 there was actually a party running for the federal election and one of the headlines was we wanted Gene Free Austria which was an interesting headline so this is basically what I was facing you know and then I went into the public I said you know listen genetic engineering might be some benefits just let's think about this I got death threats people tried to kick me out from the country and so on so now you know it's really difficult in this milieu but now with COVID I think this has the playground has completely changed so this is also a game changer I feel also a death level but everybody now accepts you know the importance of science that science can teach us something and so I think there's a game changer at multiple levels and of course also in engagement because now I think engaging with each much more people if we engage I gave a public lecture I think at the beginning of COVID was really funny because most of the things I predicted actually happened and everybody sold them a total fool which is interesting but there's just knowledge from the first SARS outbreak there was no rocket science vision it was just normal 150,000 people watched you know it was 10 years ago there was no way you would reach people like this that's really interesting I got another great question from Kelsey Berry so Kelsey says in my work I have observed small biotech companies evaluating potential funding from government agencies from a point of concern that if they accept it they're now to prioritize the U.S. in their subsequent distribution strategies have you encountered a similar circumstance are there promising alternatives that you've identified oh my god national barriers and drug development yes I mean yes permanently you know and I mean the U.S. FDA is great but also having an international perspective to support primarily U.S. drug development is a European company it's very difficult it's a small company of course if you're big then it's fine so yes I think there should be ways to do this better you know when they run a clinical trial in China they should accept it also in Europe of course different ethnic populations and one has to be careful with side effect profiles but I think there could be much larger global outreach and this would actually speed up drug development massively and of course there are different business models in biotech I started various biotech companies in the U.S. if you go also Canada you're selling your soul to the private investors which is a single project and if your project is dead then we do something else in Europe it's most we get mostly first funding from governments at least you can get going and now actually we worked with China we started a biotech in China which is another class U.S. China relations I find is totally silly why do we do this why do we do biomedical research and drug development to help people there's no borders for diseases we know for COVID what's this fighting in China it's bad for and I know because I asked some friends in Boston to get involved and the first way because if you get involved we might get ostracized by the U.S. government and I hope this is improving but at the end of the day seriously it's about fundamental understanding of diseases a community and finding solution I mean if you develop a drug in China or in Nigeria or in Europe or in Boston I mean as a patient I could care less I think this is where we really have to get the global community but they see it all the time and in China the business model is yet completely different again they actually give us a lot of money and we still own 90% of the companies it's the opposite what's happening in the U.S. of course no money is free let's face this we will be free no money of investors are free so in that sense I personally if the U.S. government a small biotech in Boston and I get money from the U.S. government to run my program I will take it so one last question for you before we wrap up what ethical concerns do you have about your research are there any ethical questions that you think about or that you mull over it's all the time I mean to quote Dostoyevsky's brother Karamazov every stick has two ends the stick of benefit the stick of maybe something else and I think it's always of course what's in the greater public good and let's face it the technologies which are being developed can be used for other purposes advisory board for many years in Europe actually somebody said CRISPR is great because now we could make a particular engineer something which would kill somebody from military could actually kill an ethnic subgroup because it's more specific of course we know CRISPR is great and the new medicine and you know so yes I mean but that's really your domain so I'm for me it's a really slippery ice rink because you know the sciences and you know this is pushing ahead you know next experiment you know what's possible let's make a you know in viral virology let's make much more infectious virus let's reanimate the Spanish flu virus you know and some people say wait a minute you know if this escapes from the lab so what do we do then and of course the other argument well we best understand the system which is true I mean so that was always my world you know push ahead and let's see what's possible but I think we very much have to to consider the ethnic ethical implication for me I'm a trained medical doctor so for me the reason why I do this and use new technologies and developed also new technologies is you know because I truly believe there's so much to learn we're just at the surface of understanding and so much to learn and there's such a need to you know as a medical doctor that's my core I want to help people it might sound pathetic but that's why I do this stuff and then I think it's okay then you can also justify for yourself how you might develop technologies which could be misused and for this vision I think the same for biotech development and if you start biotechs if you go into this to make money that's the wrong approach because it will be so difficult to get this and so many little shins which could happen and you invest tens of millions and there's one side effect you didn't anticipate and the whole program so if you go into this for this vision you know I want to make more money I think that's the wrong business I think we should always know why we do this where do we want to go and for me as a trained doctor I want to develop drugs from understanding to development to help somebody end of story and I think that's why I can accept for myself the ethical implications what this could also mean for animal testing but we do, it's not nice let's face it all of us know this so how do we justify this for myself well thank you so much for your presentation and your very heartfelt comments during the discussion I really appreciate your knowledge that you shared with us and your honesty so I want to thank everybody for joining us in this special program today and I also want to thank the Center for Bioethics at Harvard Medical School for sponsoring this consortium series and I want to thank Ashley Troutman for all of her logistical help on this please join us next month on December 10th the topic there is gene drives and that is an event co-sponsored by Aaron Kesselheim's Health Policy Consortia so we'll see you then on December 10th until then have a great weekend thank you for joining us