Joel P Joseph Biological Sciences, Interviews, Medicine

A viral conversation: Interview with Dr G Arun Kumar

Dr G. Arun Kumar, currently heading Manipal Institute of Virology (MIV) under Manipal Academy of Higher Education (MAHE), is a renowned Indian microbiologist and virologist. He also heads the Regional Reference Laboratory for Influenza viruses established by Ministry of Health and Family Welfare, Government of India at Manipal and the ICMR Virology Network Laboratory (Grade-1) at Manipal. He is the pioneering scientist, who established the virology facility in Manipal with the support of the University and the Government. His research interests include viral diseases, epidemiology and diagnostic virology and public health response during infectious disease outbreaks. He led the team that was instrumental in containing the first Nipah Virus outbreak in South India. He is an expert member of several national and international committees pertinent to public health. 

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Dr G. Arun Kumar at Manipal Institute of Virology

How did you come to join Manipal Academy of Higher Education and how was the virology facility set up there?

I came to Manipal in 1994 to pursue MSc in Medical Microbiology after my BSc in Medical Laboratory Technology from Trivandrum Medical College. It was within a year since Manipal had become a deemed university. As soon as I finished MSc, I received the CSIR-JRF fellowship and went to the All India Institute of Medical Sciences (AIIMS), Delhi, to pursue my PhD in Virology.

About six months into AIIMS, as I was preparing to register for PhD there, my Professor from Manipal, Dr P G Shivananda MD, PhD., wrote to me asking me to join them. It was a difficult decision to take as Manipal did not have a virology lab at that time. The risk-benefit analysis showed that it was risky to move to Manipal. But my professor was insistent and promised me to provide a small facility for virology. I also discussed these things with my guide Dr Pradeep Seth, MD at AIIMS, New Delhi, and he also suggested taking up Manipal’s offer. I then thought that moving to Manipal was a challenge I had to take up – to initiate something that would have a lasting impact not only on me but also on the institution.

So, I joined Manipal as a lecturer in Nov 1997. I wrote a proposal to Prof. M. S. Valliathan, the then Vice-Chancellor of MAHE, through my professor, Dr P G Shivananda, to establish a virology laboratory. After a year, INR 500,000 was granted to set up a virology facility. That is how the virology lab was set up in Manipal and I came to be associated with it.

How did this facility grow to be an internationally renowned institute?

In May 1999, we set up a small lab with viral serology, tissue culture and virus isolation facility and started working on some clinically relevant viruses. We started the work with Respiratory Syncytial Virus (RSV) as I had worked on it in AIIMS and was familiar with it. I also started my PhD on RSV and completed it in 2002. By then we were actively working on 4 to 5 viruses and were providing diagnostics for it. This was also the time when we started attending conferences and people started noticing our work.

In 2003, there was a huge outbreak of SARS in Hong Kong. Government of India started looking at developing the capacity to detect and fight this virus. A review committee emphasized the requirement for more virology labs in India. The government also wanted to prepare the country for Avian Influenza (bird flu) Virus. Fortunately for us, without our knowledge, our facility was identified as a potential lab to be supported to work on these programs.

In 2007, we got a letter from the Indian Council of Medical Research (ICMR) asking if we were willing to develop the lab to a state-level virus diagnostic and research laboratory (VRDL). Following an expert site visit and a detailed project proposal review in 2010, they sanctioned a grant of INR 5 crore for a period of five years.  Meanwhile National Centre for Diseases Control (NCDC), Delhi had included our lab under the network of regional influenza laboratories.  This enabled our facility to be notified as a reference laboratory for influenza A H1N1 when the pandemic influenza arrived in India in 2009. The ICMR- VRDL facility was established in March 2010. Subsequently, realizing the potential of the lab, MAHE elevated it as a University department – Manipal Centre for Viral Research (MCVR). Now I had to report directly to the Pro-Vice-Chancellor of the university. This removed many hurdles and facilitated a faster decision-making process. We also moved into a new building with the support of the university. In this way, we grew in close association with the State and Central Health Services in India in the area of disease surveillance

In 2013, we had another quantum leap when we received a foreign grant from the Centre for Disease Control (CDC), USA as part of the global health security agenda (GHSA). We were awarded a sum of USD 250,000 to study emerging pathogens in the human-animal interface. We started the study in Shimoga, Karnataka. It progressed well and we received an upgrade of the award in 2015 to carry out the study in ten states in India. With that our funding had increased and our capacity grew tremendously. This enabled us to become a centre for excellence in disease surveillance and outbreak investigations.

In this way, we grew with the support of the university and the Government of India. We received several grants from the government and the university provided us with the infrastructural support. Manipal provided enormous support, space and freedom to grow and implement some of the dreams I had. The support has continued and now we have been elevated as independent institute – Manipal Institute of Virology (MIV) – under the university with higher containment labs and facilities.

MCVR (now MIV) did an excellent job in checking the Nipah virus outbreak. How did you go about detecting this rare virus?

Since 2009, we have been working very closely with Kerala on the detection of Pandemic Influenza. Besides the Influenza virus, we would also run diagnostic tests for other viruses in many cases. Gradually, many doctors of Kerala gained confidence in our viral detection tests and we developed a close relationship with the doctors. Baby Memorial Hospital at Calicut was one of the hospitals we had been closely working with.

In May 2018, a patient with symptoms of Encephalitis came to Dr Anoop Kumar at Baby Memorial Hospital. His brother had died with a similar illness 12 days earlier and two others in his family were also sick. This cluster of brain fever in a family raised an alarm. There were two possibilities viz., (i) Serial Poisoning (ii) An infection. When Dr Anoop called me around lunchtime on May 17, 2018, and explained the case, I sensed that it was a serious case. I directed him to collect multiple clinical samples and asked him to send it across quickly by hand. In a usual case, the samples are collected through a nodal officer at the district and are sent as a batch by train either daily or on alternate days.

In our primary investigation of this sample, in addition to the test for common Encephalitis agents like Herpes Simplex Virus and Japanese Encephalitis Virus, we tested for Nipah Virus as well. In the usual case of Encephalitis from Kerala of Karnataka, we would never consider testing for Nipah in the first set. But we considered it because of our understanding of Nipah epidemiology and knew that Nipah presents as a family cluster of encephalitis. Nipah virus testing was not new for us. In our fever study program in Assam and Tripura, we had tested samples for Nipah in the border areas close to Bangladesh (Bangladesh has been reporting Nipah cases every year since 2001) but didn’t detect any. That is why we considered it in our primary investigation and it turned out that the patient was positive for Nipah. But since this was from a different region, we were sceptical. We wanted to be sure. So we tested for about 30 other agents and by evening we were sure that it was Nipah only.

How did you tackle the situation when you realized that you were dealing with this deadly virus? What were the measures you took to rise to this public health challenge?

By the evening of May 17, 2018, we knew that we were dealing with Nipah. But you cannot announce it right away as it would have implications on national and international mobility. We also had to be absolutely sure of the agent. But the information had to be conveyed quickly to contain the virus and avoid transmission.

So immediately we sent the samples to National Institute of Virology (NIV), Pune, for a reconfirmation. In the meantime, we alerted the central and the state government authorities about the virus without naming it and urged the hospitals to isolate people who had come in contact with the patient.

Kerala responded to this situation in a very positive way. The health department instructed the hospitals about isolation procedures and patient care. The healthcare workers were pro-active, and the public also responded well.

The Hon. Health Minister of Kerala Smt. KK Shailaja teacher asked me to join them on the field as very little was known about this outbreak and had to be investigated. When we got there, we realized that there were several undiagnosed deaths in the medical college that week. Fortunately, the samples were preserved for few cases at least and they turned out to be positive for Nipah.

But these cases had no obvious connection to the first patient or the family. This was frightening. By this time the public and the government were growing restless and wanted to know what was happening. If these cases were not linked to the first cluster, we would have to consider the case of a biothreat. But Nipah is a difficult agent and is usually not used as a bioweapon. We launched a thorough epidemiological and virological investigation and traced those who had come in contact with the initial patients, isolated them and put them under surveillance. The health department of Kerala had already started isolation procedures on the night on May 18.

We then went into a detailed investigation of the first case, twelve days before the reported death. The patient was hospitalized in the Taluk hospital for one day and in the Medical College Hospital for another day. The Taluk hospital had already been evacuated, but the staff recreated the scene of the original patient in the ward. He had cough, vomiting, and irritability. His father and brother had attended to him and there were some deaths from the same ward because of human to human transmission. Nine cases were thus linked to this hospital.

When we tried to trace the other cases, we found an intriguing association with the radiology corridor of the Calicut medical college. Investigations revealed that the index case when admitted to Calicut medical college was subjected to a CT scanning on 5 May and most of the cases had exposure to index case that day. The index case was moved around the CT scan room and in the corridor for about four hours since it was difficult to get his scan due to his altered sensorium and irritability. CCTV footages helped trace this exposure.  Once this link was established, we were relieved. Health department identified all contacts of these people and isolated all symptomatic cases and the situation came under control.

After this, the health department called for a meeting with News Editors and discussed the situation. We made them aware that Nipah is transmitted by droplets, where the person had to be within one-meter vicinity of the patient for it to be transmitted and not by aerosol (Airborne). At the start of the meeting, about 60% were wearing masks and at the end of it, no one was wearing a mask as the mask was required only for persons in close contact with the patient. This communication helped a lot to clear the public fear.

In retrospect, how do you view this achievement of Nipah intervention and what do you think about it?

Looking back, I think there were some critical junctures where important decisions had to be taken. The district administration was very supportive and was with the health team all the time. There was very good participation and intervention by the state and central health services. Hon. Health minister of Kerala Smt. KK Shailaja Teacher, The Additional Chief Secretary of Health department Sri. Rajeev Sadanandan and the Director of Health Services Dr RL Sarita has provided exceptional leadership. The Nipah emergency operation room at Calicut worked flawlessly in coordinating the response. It was a very good model and I am afraid if it can be replicated in other places.

Recently, Manipal Institute of Virology was added as a centre of Excellence within Global Virus Network (GVN). Could you please tell me a little bit about GVN and how you view this addition?

Global Virus Network (GVN) was founded by Robert Gallo, who won the second Lasker Award for the discovery of HIV, in conjunction with William Hall of University College London and Reinhard Kurth of the Robert Koch Institute. It is a Non-Government network that brings virologists and institutes together in a collaborative effort to fight viral infections.

The idea of the network is to develop expertise through centres for excellence and to exchange it among them to act quickly during an outbreak. The aims of the network include collaboration among virus scholars, expansion of virologist training programs, and evidence-based policy advocacy. The network also collaborates with WHO and gives expert opinion helping in framing evidence-driven policies.

I think our addition to the GVN will help us in building our capacity, be instrumental in framing evidence-based policies and to work on one health – a concept that tells that the health of people is connected to the health of animals and the environment, which is nascent in India. This collaboration is going to help us in the study of these aspects.

What is your vision for MIV for the next 10 years?

As we are transitioning from a centre to an Institute we are redefining our vision and goals. In the next ten years, we envisage transforming MIV to the most preferred place for infectious diseases researchers especially in the area of emerging and re-emerging diseases.  We will enable and nurture basic, translational and public health virology research which is designed to contribute to achieving the sustainable developmental goals.

As a person who has been instrumental in building a centre of excellence in research, what is your advice for other academicians treading the path?

Three things are important to build a department or institution: (i) Your team: You need people who stay with you and understand your vision and philosophy (ii) An enabling leadership and environment (iii) Liaison with government systems and stakeholders.

It is also important that you grow in a niche area. For example, we specialized in disease surveillance, outbreak detection and pathogen detection, which requires quick mobilisation the team in the field.

However, it is important to periodically identify the strengths, weaknesses, opportunities and threats and strategize to reinvigorate the growth rate.

Joel P Joseph Biological Sciences, Medicine, Motivational

The Nobel winners, 2019: Physician-scientists who discovered how cells adapt to changing oxygen levels

The Nobel Prize in Physiology or Medicine, 2019 was awarded to Gregg L. Semenza, William G. Kaelin Jr. and Peter J. Ratcliffe and for their work on how cells sense and adapt to oxygen availability. Their research elucidated the genetic mechanisms through which cells respond to changes in oxygen levels. The findings have implications in treating many diseases, including cancer, anaemia, heart attacks and strokes. These scientists had also shared the Albert Lasker Basic Medical Research Award in 2016. 

Nobel 2019

Left to Right: William G. Kaelin Jr., Sir Peter J. Ratcliffe, Gregg L. Semenza

If Semenza, Kaelin and Ratcliffe had one thing in common, besides their area of research, it is that they chose to publish houses of brick rather than mansions of straw. It sure took a while for the world to notice them, but it did.

About the papers that earned him the Lasker, Kaelin wrote, “Most would be considered quaint, preliminary and barely publishable today.” These papers would get him the Nobel Prize three years later.

Semenza and Kaelin woke up to the call from the Nobel media that day. While Semenza’s first reaction was to hug his wife, Kaelin told Adam Smith – the Chief Scientific Officer of Nobel media – how he missed his late wife on that occasion. Ratcliffe, on the other hand, was working on a grant when Smith called him. “I was writing and will continue to write an EU Synergy grant for collaborative work with friends and colleagues in Finland, and also my good friend and colleague Christopher Schofield, so of course the EU’s on our minds at the moment, and we’re writing a Synergy grant. And despite this good news, I guess I’ll continue doing that and meet the deadline,” Ratcliffe said.

What made these scientists embark on their journey in research is worth knowing. In an interview with The Journal of Clinical Investigation (JCI) in 2016, Semenza said that it was his high school biology teacher, Rose Nelson, who inspired him to pursue biology. “I had her as a freshman for biology and then as a senior for AP biology when it was genetics within biology that I got really excited about. With her help, I was able to enrol in an NSF-sponsored summer program at the Boyce Thompson Institute for plant research. It was really my first exposure to research and experiments,” he said. His interest in genetics and his meeting with a family friend’s child, who had Down syndrome, motivated him to pursue MD-PhD to study genetics and to care for those with genetic disorders.

It wasn’t easy for him at this stage either. Being the first graduate student of the lab with a very ambitious project in hand, he had reached the stage where he felt it wasn’t working out. He then switched to another lab at Children’s Hospital of Philadelphia in the second year, where he studied β-thalassemia.

“I was tasked with studying an unusual family, where one of the alleles was a silent carrier,” Semenza told JCI. “Normally, you can tell from looking at the blood cells whether someone is a carrier. In this case, it was the father who was an obligate carrier, as he had two affected children, but you couldn’t tell he was a carrier. It was suggested that the mutation was in some way different; this was going to be my project. The idea was that you take the blood, isolate the DNA, make a library, pull out the β-globin gene, and sequence it. I did all that and at the end of one year, I got the sequence, and the mutation was the exact same mutation as the previous study, which meant that somehow the clone had become contaminated, and the whole thing had been for nothing. So now I was going to have to start over the third time. I went back, started over again; things went smoothly because technically I’d already done it, and we went through the project and got an answer.”

He then moved to Johns Hopkins for his post-doctoral education, where he worked with Haig Kazazian and Stylianos Antonarakis – leaders in finding the molecular basis of β-thalassemia. He started working on this gene called Erythropoietin (EPO), which Chuck Shoemaker from Genetics Institute in Cambridge had asked Kazazian and Antonarakis to consider. Semenza tried to identify the DNA sequences in the gene responsible for its expression in different tissues. They put different fragments of human DNA spanning the EPO gene into mice and checked if and where the gene was expressed.

This was the turning point for Semenza. He figured that the gene was regulated by oxygen. Now, he had to understand where these DNA sequences regulated by oxygen were located. On investigating further, he realized that this sequence was in the DNA sequence that came after the gene (3’ flanking sequence). This was unusual as such regulating regions usually lie before the gene (5’ flanking sequence). But the data said that it was the 3’ flanking sequence. So, they took this sequence and put them in a plasmid which had a reporter. They then put this plasmid inside human cells grown in the dish and deprived them of oxygen. At low oxygen levels, the EPO gene would be expressed because of the sequence present in the plasmid. They then made smaller fragments of that sequence and repeated the process until they got down to 33 base pairs. On mutating individual nucleotides in this region, they found that the EPO gene expression was stopped.

“We suspected that there was a very important factor, which was binding to that sequence and was responsible for turning on the gene. And so, we tried to find the protein that was the key factor for turning on the EPO gene,” Semenza told JCI.

At this point, he was a young faculty with a post-doctoral fellow, Guang Wang. Semenza and Wang started looking for a protein that would bind to this DNA sequence (Hypoxia Responsive Element). The challenge was to figure out the conditions that allowed binding. They were also hoping to find something that would be present in the nucleus of cells with low oxygen (hypoxic) but absent in those with normal oxygen levels (normoxic). “Guang would do several of these experiments a day and had this stack of blots with negative results on his desk. I was thumbing through them one day, and I came across this one gel where there seemed to be a faint band in the hypoxic lane. I got all excited and said, ‘Did you see this? Did you see this?’ After optimizing the assay in a very short period of time, he generated really strong definitive results of a binding activity that we called hypoxia-inducible factor 1,” Semenza said.

For Ratcliffe, the start was serendipitous. In his Lasker acceptance speech, Ratcliffe reflects on an incident from his days at the Lancaster Royal Grammar School for the boys. “I was a terrible schoolboy chemist and following the career of some distant relative, I was keen to study industrial chemistry. One day the ethereal but formidable headmaster appeared in the chemistry laboratory, summoned me to one side, and said, ‘Ratcliffe, I think you should study medicine.’ I said ‘Yes, Sir’ decisively. Without further thought, the university application papers were changed accordingly,” he said. “To this day, I don’t really know whether he felt I would be a good doctor or a bad chemist. But the moment sticks with me as a reminder of the importance of serendipity in a scientific career, at least in mine,” he added.

He trained in Medicine as a Kidney specialist and started his research career fascinated by the extraordinary sensitivity with which the kidneys regulate the hormone Erythropoietin (EPO) to regulate red blood cell production. “I felt that the problem was interesting, conceivably attractable and there was a new opportunity for study with the cloning of the erythropoietin gene. But some people felt, with the emerging success of recombinant Erythropoietin, that understanding how the hormone was regulated was a niche area unlikely to be of very general importance. They advised me accordingly to study something else,” he said.

In the telephone interview with Nobel Media, Kaelin shared what drew him to science. “You know, I’m a big believer of curiosity-driven, hypothesis-driven research,” he said. “I know that’s complementary to other ways of generating knowledge but I think in the end what drew me to science and what draws a lot of scientists to science is that we like interesting puzzles, like clinical features of patients who had mutations in the VHL gene, were a curious constellation of findings but one way to unify them was there was some abnormality in the way the tumours they were developing were sensing and responding to oxygen, and we thought if we could understand that we could understand more globally how cells and tissues sense and respond to changes in oxygen.”

Little did these physician-scientists know while addressing their research problems, that they were reaching for the Nobel with their findings. But that’s the beauty of Science. Think about these Nobel laureates. As someone who made a serendipitous entry into medicine later pursuing an area of research, which many thought had no scope beyond the niche area of kidney research, Ratcliffe won the Nobel Prize for the findings that have immense physiological importance. Sharing the award with him are Semenza, who struggled in the early days of PhD and found his way through, and Kaelin, whose pre-medical school mentor remarked on his college transcript, “Mr. Kaelin appears to be a bright young man, whose future lies outside of the laboratory.” Their life and work are a testament to the fact that houses of brick stand the test of time.

Sources:

Kaelin Jr., William G. (2017). Publish houses of brick, not mansions of straw. Nature. Retrieved from https://www.nature.com/news/publish-houses-of-brick-not-mansions-of-straw-1.22029

Neill, Ushma S. (2016). A conversation with Gregg Semenza. The Journal of Clinical Investigation.  Retrieved from https://www.jci.org/articles/view/90960

Albert and Mary Lasker Foundation. Peter Ratcliffe, Acceptance Speech, 2016 Lasker Awards. Retrieved from https://www.youtube.com/watch?v=wB5gzwZMvTM

Albert and Mary Lasker Foundation. William Kaelin Jr, Acceptance Speech, 2016 Lasker Awards. Retrieved from https://www.youtube.com/watch?v=K2Ds_S48IWg&t=54s.

Sir Peter J. Ratcliffe Interview. Retrieved from https://www.nobelprize.org/prizes/medicine/2019/ratcliffe/interview/

William G. Kaelin Jr. Interview. Retrieved from https://www.nobelprize.org/prizes/medicine/2019/kaelin/interview/

Gregg L. Semenza Interview. Retrieved from https://www.nobelprize.org/prizes/medicine/2019/semenza/interview/