Thread by @ReformedTrader

1/ Shot to Save the World: The Inside Story of the Life-or-Death Race for a COVID-19 Vaccine (Gregory Zuckerman)

"Developing, testing, manufacturing, and delivering effective vaccines within a single year is a feat unmatched in modern science." (p. xiv)

amazon.com/Shot-Save-Worl…

2/ "Until 2020, a mumps vaccine was the fastest ever developed, and that took a long four years. The average vaccine was produced in ten years.

"Many of the world’s biggest drug and vaccine makers were slow to react to the pandemic or couldn’t muster an effective response.

3/ " Instead, untested individuals stepped up: a French executive dismissed by some as a fabulist, a Turkish immigrant w/ little experience working on viruses, a quirky midwesterner obsessed with insect cells, a Boston scientist employing questionable, even dangerous techniques,

4/ "a British scientist detested by his peers.

"Far from the limelight, each had spent years developing innovative vaccine approaches. By 2020, these individuals had little proof of progress.

"This is the story of what finally went right." (p. xvii)

5/ "Much of the scientific community snickered at the idea. They all knew that mRNA was too unstable to create proteins in the body, at least on a consistent and reliable basis." (p. xx)

"The human immune system features two lines of defense.

6/ "A fast-acting, first-line “innate” immune system is composed of various white blood cells, such as macrophages, dendritic cells, and natural killer cells that stand guard at the body’s gateways—the skin, nose, throat, etc.—to detect and fend off viruses and other invaders.

7/ "The innate immune system doesn’t need prior exposure to a pathogen to be activated against it, but it can have trouble handling especially powerful or clever pathogens. For these difficult battles, the body’s “adaptive” immune system joins the fight.

8/ "Sensing danger, it sends other kinds of white blood cells, including T cells, which can recognize specific pathogens, and B lymphocytes, or B cells, which produce powerful antibodies. The problem is that the adaptive immune system is strong but a bit slow." (p. 7)

9/ "Vaccines usually are losing propositions. The hurdles to gaining regulatory approval are high, government reimbursements can be inadequate, and manufacturing and other costs are imposing. Vaccine makers also contend with liability worries if their shots go awry." (p. 28)

10/ "Most of those focused on AIDS vaccines were smaller companies with little to lose. For them, success might bring an elevated profile, new investors, and a chance to pursue more lucrative scientific efforts—benefits that outweighed the enormous costs.

11/ "By the mid-1990s, some companies and academic institutions had turned their attention to cancer, neurology, and other promising medical fields. Still, a core group of scientists kept working on HIV, scoring under-the-radar advances they hoped might pay off someday.

12/ "Some of these accomplishments might sound obvious, even mundane, such as achieving a better understanding of the complex workings of the immune system and how it interacts with invading pathogens. In the past, though, this basic knowledge hadn’t always been necessary.

13/ "For all their historic triumphs, vaccine pioneers often employed hit-or-miss approaches. Grab a piece of a pathogen, undertake repeated experiments to weaken or kill it, and try to find the right amount of the virus to use as the basis of a vaccine.

14/ "Even Jonas Salk, Albert Sabin, and other vaccine heroes usually lacked a mastery of the diseases they were combating or a full understanding of why vaccines worked. They weren’t ashamed to acknowledge the huge role that serendipity played in their discoveries." (p. 29)

15/ "When Karikó & Weissman were putting mRNA in cells in tissue culture, they didn’t have to worry about the immune system fighting back. Now that they were injecting it in animals, they were setting off inflammatory cytokines, inadvertently activating the first line of defense.

16/ "It was as if the mice cells were so threatened by the injected molecule that they were damaging themselves to avoid having anything to do with it.

"mRNA wasn’t simply fragile and short-lived. The molecule was setting off a ruinous immune-system reaction and cell death.

17/ "They eventually identified certain receptors in mammalian cells that act as lookouts, spotting foreign bodies like the mRNA and triggering the harsh immune response that was damaging their mice. Next, they had to find a way for their mRNA to evade these receptors.

18/ "Using pseudouridine instead of uridine caused the cell’s immune system to ignore the mRNA." (p. 78)

"Warren, Rossi, and their colleagues had used modified mRNA to reprogram adult skin cells into pluripotent cells and produce human proteins.

19/ "Warren and Rossi were the first to show that something potentially therapeutic could be produced from mRNA and that they could turn cellular clocks back." (p. 102)

Related reading:

https://twitter.com/ReformedTrader/status/1382766571957882881

20/ "Afeyan became intrigued about using mRNA to create specific proteins. Need a statin, immunosuppressive, or other drug? Just use mRNA to send a message to the body’s cells. mRNA might be able turn the body into its own laboratory, generating medications as needed." (p. 104)

21/ "Karikó and Weissman had swapped uridine for pseudouridine to evade the cellular immune response. Schrum found that a variant of pseudouridine called N1-methyl-pseudouridine did an even better job reducing innate immune response.

22/ "Schrum’s nucleoside switch enabled even higher protein production than Karikó and Weissman had generated. Schrum’s mRNAs lasted longer than either unmodified molecules or the modified mRNA the Penn academics had used.

23/ "Now there was a potential way for mRNA to produce proteins in large enough quantities to potentially be used as drugs. Afeyan and his partners were convinced they were on to something special. Rossi branded the new company Moderna, a mash-up of “modified” & “RNA.” " (p. 110)

24/ "Using mRNA for drugs would mean developing the same fast process each time, relying on a specific sequence of genetic code & cheap enzymes to produce each protein, avoiding the enormous costs that come with building factories and dealing with cells for traditional medicines.

25/ "DNA wouldn’t be directly involved, so there wouldn’t be a risk of causing mutations as with gene therapy. The mRNA approach was so new and unique it likely wouldn’t infringe on existing patents: almost every kind of medicine could be produced without legal troubles." (p.116)

26/ "One group was assigned to run a massive safety study in monkeys to show mRNA wasn’t toxic, while others were told to produce one hundred different proteins in mice and rats.

"Moderna began a frenzied effort to file patents, one for each new protein produced,

27/ "hoping to stake claims before others had a chance. Soon staffers were filing patents even before doing lab experiments proving they could create the proteins, all in a mad rush to accumulate intellectual property so drugs could be rolled out." (p. 116)

28/ "Bancel spoke to his team about future pandemics, and how the technology the company was developing could save lives, partly because mRNA is so much faster than other drug and vaccine approaches. “We just have to be ready.” " (p. 120)

29/ "Almost all Moderna's mRNA was getting cut up and eliminated by an enzyme called a nuclease, well before the molecule could get into the cell. To address this problem, the researchers began inserting their mRNA in lipid nanoparticles (LNPs), tiny balls of cholesterol and fat.

30/ "But the scientists ran into a huge new problem. When they first administrated their mRNA encased in LNP to mice and monkey test subjects, it generated impressive amounts of protein. Within a week or so, though, subsequent administrations saw the protein production plummet.

31/ "It was as if the body’s defenses had learned to fend off the molecule. mRNA pioneers had never done repeated dosings, nor were they trying to produce enough protein for drugs, so they didn’t need complex LNPs and never experienced this “transient protein expression” issue.

32/ "Everyone at Moderna was looking at what their mRNA couldn’t do, namely create potent and plentiful proteins after repeated dosings. Huang focused on what it could do: get into cells and create ample, if short-lived, proteins, before the mRNA was eliminated.

33/ "Somehow their mRNA/LNP combinations, when injected in the muscle, were delivering a payload to the lymph nodes that was eliciting a strong immune response, even at very low doses.

"In 2013, Huang brought his idea to Hoge: Moderna should be making vaccines, not drugs.

34/ "Hoge found Huang’s argument persuasive, but he had qualms about focusing on vaccines. Moderna had sold itself to investors and partners as a company that could produce proteins to help those suffering from diseases. Its goal was a pipeline of medicines, not vaccines.

35/ "Everyone knew vaccines were a low-margin, boring business.

"Nevertheless, Hoge asked Huang to build an influenza vaccine using mRNA and test it in mice.

36/ "The mRNA, which stimulated an immune response by producing a key influenza protein in the mice, achieved startling antibody levels, or titers, in blood. Protection was 100x higher than for existing flu vaccines as well as for other approaches, such as naked mRNA." (p. 130)

37/ "For decades, coronaviruses were viewed as obscure and largely inconsequential. These pathogens could cause severe sickness in pigs, chickens, dogs, cats, and mice. For humans, though, they were responsible for little more than the common cold." (p. 137)

38/ "In 2002, a very different kind of coronavirus emerged in Guangdong Province in southern China, likely from bat poop that reached humans via catlike mammals called civets. The virus infected food workers and then spread to hospital staffers,

39/ "one of whom unwittingly brought the virus to a Hong Kong hotel. Soon it spread around the world. The pathogen was named SARS-associated coronavirus, or SARS-CoV, and the disease was called SARS (severe acute respiratory syndrome). It had a mortality rate of 10%.

40/ "SARS-CoV disappeared in about eight months, though, killing fewer than one thousand people. Early adoption of mask wearing, handwashing, and temperature-taking ended the epidemic.

41/ "The virus was primarily spread by those who were ill, not asymptomatic people, so isolation and contact tracing were effective.

"MERS was even more lethal than SARS, with a 36 percent mortality rate, though it wasn’t as transmissible among humans." (p. 141)

42/ "The body’s adaptive immune system sometimes needs help recognizing both friends and foes. Once educated, though, it tends to remember, remaining primed to fight its enemies for months or even years. The challenge is finding a way to teach the body how to detect a pathogen.

43/ "The immune system needs to see only a small, unique portion of a virus to recognize it. But scientists first have to identify what piece or pieces of a virus are its most distinctive feature.

"That’s what the spike protein is—the coronavirus’s most distinctive trait.

44/ "McLellan and Wang knew if they could build a version of MERS-CoV’s spike protein and expose it to the body’s immune system, protective antibodies would be generated and they wouldn’t have to inject a piece or version of the actual virus. For months, they met frustration.

45/ "Much like RSV’s F protein, the spike protein on the surface of MERS-CoV wouldn’t sit still, changing shape before and after infecting cells.

"The immune system needed to see the protein in its prefusion stage to produce protective antibodies,

46/ "but protein modifications that had worked for RSV weren’t locking MERS-CoV’s spike protein in place, nor were other, more traditional techniques McLellan and Wang tried.

"Wang designed a genetic sequence that added two rigid prolines to the stem of MERS-CoV’s spike protein.

47/ "Like contractors redesigning a building, Wang and McLellan added scaffolding to keep their structure from collapsing. In 2016, Wang took their genetic code, inserted it into a culture of human cells, and found that it produced a stable version of the spike protein." (p. 145)

48/ "Wang had submitted a paper detailing their MERS research, demonstrating a potentially universal method of stabilizing the coronavirus’s spike protein to enable an effective vaccine, but the paper had been rejected by all five of the leading scientific journals.

49/ "One reviewer called their data an “artifact,” while another decided they “did not provide a broad conceptual advance.” " (p. 146)

"Publications don’t define talent and achievement, he realized. “I accepted myself and struggled to climb from the bottom.”

50/ "The researchers didn’t have proof their approach worked, and they’d need help to make it into an effective vaccine.

"They and their colleagues needed a company to produce their MERS shots and find an effective way to consistently get it into the body’s cells." (p. 148)

51/ "Moderna's scientists were injecting shots deep into the muscle of mice, but their immune systems were mounting spirited responses to the foreign components of the lipid nanoparticles (LNPs), especially upon repeated dosing.

"The LNPs also produced drastic side effects.

52/ "A vaccine or drug that caused sharp pain and awful fevers wasn’t going to prove very popular." (p. 150)

"All LNP packaging, including the one from the Canadians, can generate problematic reactions as lipids accumulate in injection sites." (p. 151)

53/ "Benenato tried simpler chemicals. She inserted ester bonds, which the body can grab and break apart. They were strong enough to help ensure the LNP remained stable, acting much like a drop of oil in water but also gave the body’s enzymes something to target and break down.

54/ "She also wanted to try replacing a group of unnatural chemicals in the LNP that was contributing to the spirited and unwelcome immune response. She began with ethanolamine, a colorless, natural chemical.

"The team kept tweaking the composition of the lipid encasement.

55/ "In 2017, they wrapped it around mRNA molecules and injected the new combination in mice and then monkeys. They saw plentiful, potent proteins were being produced, _and_ the lipids were quickly being eliminated." (p. 154)

56/ "Moderna quickly produced a vaccine for MERS-CoV, the coronavirus that was causing MERS. Their shots generated impressive levels of antibodies in tests on mice and monkeys, but before testing on humans could proceed, the MERS epidemic died out." (p. 156)

57/ "Journalists, investors, and others in the scientific world were on the lookout for the next Theranos. Holmes and Bancel were both smooth and telegenic salespeople who had raised a shocking amount of cash, sometimes from investors with limited scientific backgrounds.

58/ "They ran secretive companies. Weirdly, Holmes and Bancel both favored turtlenecks, à la Steve Jobs. Moderna vowed to change the world but wouldn’t share a shred of proof to back its claims; it wasn’t a good look." (p. 158)

More on Elizabeth Holmes:

https://twitter.com/ReformedTrader/status/1455974414055399426

59/ "On January 10, 2020, the genetic sequence of the virus was finally available, and scientists around the world were furiously downloading it. The virus would later would be named SARS-CoV-2. A day later, the Chinese CDC officially released the virus’s genetic information.

60/ "Zhang was thrilled, at least at first. But a day later, he began to come under pressure from Chinese authorities. They were unhappy that the nation was receiving criticism for its handling of the emerging virus and that he had released the sequence without their permission.

61/ "Holmes sent emails to senior officials saying Zhang’s act had benefited global science. It was a great moment for China. Don’t punish Zhang, he urged. Soon, though, Zhang’s lab was temporarily closed for “recertification,” and funding for his research was suspended." (p.235)

62/ "Four years earlier, Wang and McLellan had added two prolines to the stem of the MERS-CoV spike protein, holding the protein in the shape it took just before it infected host cells. For the new vaccine, Wang once again adjusted the amino acid sequence of the spike protein

63/ "to include these rigid amino acids so the body could generate a protein matching the shape of the spike protein before it fused with the body’s cells. Wang tweaked the sequence in other ways as well, such as making it soluble and removing its furin cleavage site." (p. 237)

64/ "Wang succeeded in designing genetic sequences for over a dozen different constructs, or versions, of the spike protein. Looking at his work, Wang realized his DNA sequences, based on the viral RNA sequence, would be too long and complicated for companies to quickly produce,

65/ "so he designed a way to slice them into shorter, easily synthesizable fragments. Wang sent his sequences to a gene-synthesis company to turn them into DNA. A few days later, he received a delivery of tubes full of his custom-made genetic material.

66/ "He spent the next week working with Wrapp to place the DNA in plasmids, and then put them in human cells, creating ten different versions of the spike protein, which he called nCoV 1–10." (p. 238)

67/ "The whole reason the NIH had started working with Moderna was because mRNA shots can be designed and produced faster than those based on older technologies, which usually require growing a virus in eggs or a protein in enormous vats of cells, which can take months." (p. 243)

68/ "It would cost $2 billion, money Moderna didn’t have. If it built a vaccine and failed, Moderna was doomed—investors would never forgive if they dropped everything for an ineffective vaccine or were beaten by a rival. “Should we? We’re betting the company.” " (p. 244)

69/ "BioNTech was going to push to make a vaccine before the end of 2020, faster than any had ever been made. But it only had $300 million on its balance sheet, even less than Moderna. It would need to develop, test, manufacture, and distribute shots, all very expensive." (p.248)