Spike Protein of SHC014 Known by 2015 to be an Effective ACE2 Human Receptor Binder. Jorma Jyrkkanen

March 20, 2023

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Nat Med. 2015; 21(12): 1508–1513.

Published online 2015 Nov 9. doi: 10.1038/nm.3985

PMCID: PMC4797993

NIHMSID: NIHMS766724

PMID: 26552008

A SARS-like cluster of circulating bat coronaviruses shows potential for human emergence and study indicate that group 2b viruses encoding the SHC014 spike in a wild-type backbone can efficiently use multiple orthologs of the SARS receptor human angiotensin converting enzyme II (ACE2), replicate efficiently in primary human airway cells and achieve in vitro titers equivalent to epidemic strains of SARS-CoV. Repost w emphasis on spike used by Baric and Daszak.

Vineet D Menachery,1Boyd L Yount, Jr,1Kari Debbink,1,2Sudhakar Agnihothram,3Lisa E Gralinski,1Jessica A Plante,1Rachel L Graham,1Trevor Scobey,1Xing-Yi Ge,4Eric F Donaldson,1Scott H Randell,5,6Antonio Lanzavecchia,7Wayne A Marasco,8,9Zhengli-Li Shi,4 and Ralph S Baric1,2

Author informationArticle notesCopyright and License informationDisclaimer

This article has been corrected. See Nat Med. 2016 April 6; 22(4): 446.

This article has been corrected. See Nat Med. 2020 May 22; 26(7): 1146.

Associated Revelation. Wuhan Institute of Virology Shao Cao admits they Tested Coronavirus Variants for the Best Adeherent to ACE2 Receptor

Abstract

The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome (MERS)-CoV underscores the threat of cross-species transmission events leading to outbreaks in humans. Here we examine the disease potential of a SARS-like virus, SHC014-CoV, which is currently circulating in Chinese horseshoe bat populations1. Using the SARS-CoV reverse genetics system2, we generated and characterized a chimeric virus expressing the spike of bat coronavirus SHC014 in a mouse-adapted SARS-CoV backbone. The results indicate that group 2b viruses encoding the SHC014 spike in a wild-type backbone can efficiently use multiple orthologs of the SARS receptor human angiotensin converting enzyme II (ACE2), replicate efficiently in primary human airway cells and achieve in vitro titers equivalent to epidemic strains of SARS-CoV. Additionally, in vivo experiments demonstrate replication of the chimeric virus in mouse lung with notable pathogenesis. Evaluation of available SARS-based immune-therapeutic and prophylactic modalities revealed poor efficacy; both monoclonal antibody and vaccine approaches failed to neutralize and protect from infection with CoVs using the novel spike protein. On the basis of these findings, we synthetically re-derived an infectious full-length SHC014 recombinant virus and demonstrate robust viral replication both in vitro and in vivo. Our work suggests a potential risk of SARS-CoV re-emergence from viruses currently circulating in bat populations.

Supplementary information

The online version of this article (doi:10.1038/nm.3985) contains supplementary material, which is available to authorized users.

Subject terms: Policy and public health in microbiology, Viral infection, SARS virus, Translational research

SPIKE PROTEIN CLOTTING PROBLEM

Main

The emergence of SARS-CoV heralded a new era in the cross-species transmission of severe respiratory illness with globalization leading to rapid spread around the world and massive economic impact3,4. Since then, several strains—including influenza A strains H5N1, H1N1 and H7N9 and MERS-CoV—have emerged from animal populations, causing considerable disease, mortality and economic hardship for the afflicted regions5. Although public health measures were able to stop the SARS-CoV outbreak4, recent metagenomics studies have identified sequences of closely related SARS-like viruses circulating in Chinese bat populations that may pose a future threat1,6. However, sequence data alone provides minimal insights to identify and prepare for future prepandemic viruses. Therefore, to examine the emergence potential (that is, the potential to infect humans) of circulating bat CoVs, we built a chimeric virus encoding a novel, zoonotic CoV spike protein—from the RsSHC014-CoV sequence that was isolated from Chinese horseshoe bats1—in the context of the SARS-CoV mouse-adapted backbone. The hybrid virus allowed us to evaluate the ability of the novel spike protein to cause disease independently of other necessary adaptive mutations in its natural backbone. Using this approach, we characterized CoV infection mediated by the SHC014 spike protein in primary human airway cells and in vivo, and tested the efficacy of available immune therapeutics against SHC014-CoV. Together, the strategy translates metagenomics data to help predict and prepare for future emergent viruses.

The sequences of SHC014 and the related RsWIV1-CoV show that these CoVs are the closest relatives to the epidemic SARS-CoV strains (Fig. 1a,b); however, there are important differences in the 14 residues that bind human ACE2, the receptor for SARS-CoV, including the five that are critical for host range: Y442, L472, N479, T487 and Y491 (ref. 7). In WIV1, three of these residues vary from the epidemic SARS-CoV Urbani strain, but they were not expected to alter binding to ACE2 (Supplementary Fig. 1a,b and Supplementary Table 1). This fact is confirmed by both pseudotyping experiments that measured the ability of lentiviruses encoding WIV1 spike proteins to enter cells expressing human ACE2 (Supplementary Fig. 1) and by in vitro replication assays of WIV1-CoV (ref. 1). In contrast, 7 of 14 ACE2-interaction residues in SHC014 are different from those in SARS-CoV, including all five residues critical for host range (Supplementary Fig. 1c and Supplementary Table 1). These changes, coupled with the failure of pseudotyped lentiviruses expressing the SHC014 spike to enter cells (Supplementary Fig. 1d), suggested that the SHC014 spike is unable to bind human ACE2. However, similar changes in related SARS-CoV strains had been reported to allow ACE2 binding7,8, suggesting that additional functional testing was required for verification. Therefore, we synthesized the SHC014 spike in the context of the replication-competent, mouse-adapted SARS-CoV backbone (we hereafter refer to the chimeric CoV as SHC014-MA15) to maximize the opportunity for pathogenesis and vaccine studies in mice (Supplementary Fig. 2a). Despite predictions from both structure-based modeling and pseudotyping experiments, SHC014-MA15 was viable and replicated to high titers in Vero cells (Supplementary Fig. 2b). Similarly to SARS, SHC014-MA15 also required a functional ACE2 molecule for entry and could use human, civet and bat ACE2 orthologs (Supplementary Fig. 2c,d). To test the ability of the SHC014 spike to mediate infection of the human airway, we examined the sensitivity of the human epithelial airway cell line Calu-3 2B4 (ref. 9) to infection and found robust SHC014-MA15 replication, comparable to that of SARS-CoV Urbani (Fig. 1c). To extend these findings, primary human airway epithelial (HAE) cultures were infected and showed robust replication of both viruses (Fig. 1d). Together, the data confirm the ability of viruses with the SHC014 spike to infect human airway cells and underscore the potential threat of cross-species transmission of SHC014-CoV.

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Figure 1

SARS-like viruses replicate in human airway cells and produce in vivo pathogenesis.

(a) The full-length genome sequences of representative CoVs were aligned and phylogenetically mapped as described in the Online Methods. The scale bar represents nucleotide substitutions, with only bootstrap support above 70% being labeled. The tree shows CoVs divided into three distinct phylogenetic groups, defined as α-CoVs, β-CoVs and γ-CoVs. Classical subgroup clusters are marked as 2a, 2b, 2c and 2d for the β-CoVs and as 1a and 1b for the α-CoVs. (b) Amino acid sequences of the S1 domains of the spikes of representative β-CoVs of the 2b group, including SARS-CoV, were aligned and phylogenetically mapped. The scale bar represents amino acid substitutions. (c,d) Viral replication of SARS-CoV Urbani (black) and SHC014-MA15 (green) after infection of Calu-3 2B4 cells (c) or well-differentiated, primary air-liquid interface HAE cell cultures (d) at a multiplicity of infection (MOI) of 0.01 for both cell types. Samples were collected at individual time points with biological replicates (n = 3) for both Calu-3 and HAE experiments. (e,f) Weight loss (n = 9 for SARS-CoV MA15; n = 16 for SHC014-MA15) (e) and viral replication in the lungs (n = 3 for SARS-CoV MA15; n = 4 for SHC014-MA15) (f) of 10-week-old BALB/c mice infected with 1 × 104 p.f.u. of mouse-adapted SARS-CoV MA15 (black) or SHC014-MA15 (green) via the intranasal (i.n.) route. (g,h) Representative images of lung sections stained for SARS-CoV N antigen from mice infected with SARS-CoV MA15 (n = 3 mice) (g) or SHC014-MA15 (n = 4 mice) (h) are shown. For each graph, the center value represents the group mean, and the error bars define the s.e.m. Scale bars, 1 mm.

To evaluate the role of the SHC014 spike in mediating infection in vivo, we infected 10-week-old BALB/c mice with 104 plaque-forming units (p.f.u.) of either SARS-MA15 or SHC014-MA15 (Fig. 1e–h). Animals infected with SARS-MA15 experienced rapid weight loss and lethality by 4 d post infection (d.p.i.); in contrast, SHC014-MA15 infection produced substantial weight loss (10%) but no lethality in mice (Fig. 1e). Examination of viral replication revealed nearly equivalent viral titers from the lungs of mice infected with SARS-MA15 or SHC014-MA15 (Fig. 1f). Whereas lungs from the SARS-MA15–infected mice showed robust staining in both the terminal bronchioles and the lung parenchyma 2 d.p.i. (Fig. 1g), those of SHC014-MA15–infected mice showed reduced airway antigen staining (Fig. 1h); in contrast, no deficit in antigen staining was observed in the parenchyma or in the overall histology scoring, suggesting differential infection of lung tissue for SHC014-MA15 (Supplementary Table 2). We next analyzed infection in more susceptible, aged (12-month-old) animals. SARS-MA15–infected animals rapidly lost weight and succumbed to infection (Supplementary Fig. 3a,b). SHC014-MA15 infection induced robust and sustained weight loss, but had minimal lethality. Trends in the histology and antigen staining patterns that we observed in young mice were conserved in the older animals (Supplementary Table 3). We excluded the possibility that SHC014-MA15 was mediating infection through an alternative receptor on the basis of experiments using Ace2−/− mice, which did not show weight loss or antigen staining after SHC014-MA15 infection (Supplementary Fig. 4a,b and Supplementary Table 2). Together, the data indicate that viruses with the SHC014 spike are capable of inducing weight loss in mice in the context of a virulent CoV backbone.

Given the preclinical efficacy of Ebola monoclonal antibody therapies, such as ZMApp10, we next sought to determine the efficacy of SARS-CoV monoclonal antibodies against infection with SHC014-MA15. Four broadly neutralizing human monoclonal antibodies targeting SARS-CoV spike protein had been previously reported and are probable reagents for immunotherapy11,12,13. We examined the effect of these antibodies on viral replication (expressed as percentage inhibition of viral replication) and found that whereas wild-type SARS-CoV Urbani was strongly neutralized by all four antibodies at relatively low antibody concentrations (Fig. 2a–d), neutralization varied for SHC014-MA15. Fm6, an antibody generated by phage display and escape mutants11,12, achieved only background levels of inhibition of SHC014-MA15 replication (Fig. 2a). Similarly, antibodies 230.15 and 227.14, which were derived from memory B cells of SARS-CoV–infected patients13, also failed to block SHC014-MA15 replication (Fig. 2b,c). For all three antibodies, differences between the SARS and SHC014 spike amino acid sequences corresponded to direct or adjacent residue changes found in SARS-CoV escape mutants (fm6 N479R; 230.15 L443V; 227.14 K390Q/E), which probably explains the absence of the antibodies’ neutralizing activity against SHC014. Finally, monoclonal antibody 109.8 was able to achieve 50% neutralization of SHC014-MA15, but only at high concentrations (10 μg/ml) (Fig. 2d). Together, the results demonstrate that broadly neutralizing antibodies against SARS-CoV may only have marginal efficacy against emergent SARS-like CoV strains such as SHC014.

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Figure 2

SARS-CoV monoclonal antibodies have marginal efficacy against SARS-like CoVs.

(ad) Neutralization assays evaluating efficacy (measured as reduction in the number of plaques) of a panel of monoclonal antibodies, which were all originally generated against epidemic SARS-CoV, against infection of Vero cells with SARS-CoV Urbani (black) or SHC014-MA15 (green). The antibodies tested were fm6 (n = 3 for Urbani; n = 5 for SHC014-MA15)11,12 (a), 230.15 (n = 3 for Urbani; n = 2 for SHC014-MA15) (b), 227.15 (n = 3 for Urbani; n = 5 for SHC014-MA15) (c) and 109.8 (n = 3 for Urbani; n = 2 for SHC014-MA15)13 (d). Each data point represents the group mean and error bars define the s.e.m. Note that the error bars in SARS-CoV Urbani–infected Vero cells in b,c are overlapped by the symbols and are not visible.

To evaluate the efficacy of existing vaccines against infection with SHC014-MA15, we vaccinated aged mice with double-inactivated whole SARS-CoV (DIV). Previous work showed that DIV could neutralize and protect young mice from challenge with a homologous virus14; however, the vaccine failed to protect aged animals in which augmented immune pathology was also observed, indicating the possibility of the animals being harmed because of the vaccination15. Here we found that DIV did not provide protection from challenge with SHC014-MA15 with regards to weight loss or viral titer (Supplementary Fig. 5a,b). Consistent with a previous report with other heterologous group 2b CoVs15, serum from DIV-vaccinated, aged mice also failed to neutralize SHC014-MA15 (Supplementary Fig. 5c). Notably, DIV vaccination resulted in robust immune pathology (Supplementary Table 4) and eosinophilia (Supplementary Fig. 5d–f). Together, these results confirm that the DIV vaccine would not be protective against infection with SHC014 and could possibly augment disease in the aged vaccinated group.

In contrast to vaccination of mice with DIV, the use of SHC014-MA15 as a live, attenuated vaccine showed potential cross-protection against challenge with SARS-CoV, but the results have important caveats. We infected young mice with 104 p.f.u. of SHC014-MA15 and observed them for 28 d. We then challenged the mice with SARS-MA15 at day 29 (Supplementary Fig. 6a). The prior infection of the mice with the high dose of SHC014-MA15 conferred protection against challenge with a lethal dose of SARS-MA15, although there was only a minimal SARS-CoV neutralization response from the antisera elicited 28 d after SHC014-MA15 infection (Supplementary Fig. 6b, 1:200). In the absence of a secondary antigen boost, 28 d.p.i. represents the expected peak of antibody titers and implies that there will be diminished protection against SARS-CoV over time16,17. Similar results showing protection against challenge with a lethal dose of SARS-CoV were observed in aged BALB/c mice with respect to weight loss and viral replication (Supplementary Fig. 6c,d). However, the SHC014-MA15 infection dose of 104 p.f.u. induced >10% weight loss and lethality in some aged animals (Fig. 1 and Supplementary Fig. 3). We found that vaccination with a lower dose of SHC014-MA15 (100 p.f.u.), did not induce weight loss, but it also failed to protect aged animals from a SARS-MA15 lethal dose challenge (Supplementary Fig. 6e,f). Together, the data suggest that SHC014-MA15 challenge may confer cross-protection against SARS-CoV through conserved epitopes, but the required dose induces pathogenesis and precludes use as an attenuated vaccine.

Having established that the SHC014 spike has the ability to mediate infection of human cells and cause disease in mice, we next synthesized a full-length SHC014-CoV infectious clone based on the approach used for SARS-CoV (Fig. 3a)2. Replication in Vero cells revealed no deficit for SHC014-CoV relative to that for SARS-CoV (Fig. 3b); however, SHC014-CoV was significantly (P < 0.01) attenuated in primary HAE cultures at both 24 and 48 h after infection (Fig. 3c). In vivo infection of mice demonstrated no significant weight loss but showed reduced viral replication in lungs of full-length SHC014-CoV infection, as compared to SARS-CoV Urbani (Fig. 3d,e). Together, the results establish the viability of full-length SHC014-CoV, but suggest that further adaptation is required for its replication to be equivalent to that of epidemic SARS-CoV in human respiratory cells and in mice.

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Figure 3

Full-length SHC014-CoV replicates in human airways but lacks the virulence of epidemic SARS-CoV.

(a) Schematic of the SHC014-CoV molecular clone, which was synthesized as six contiguous cDNAs (designated SHC014A, SHC014B, SHC014C, SHC014D, SHC014E and SHC014F) flanked by unique BglI sites that allowed for directed assembly of the full-length cDNA expressing open reading frames (for 1a, 1b, spike, 3, envelope, matrix, 6–8 and nucleocapsid). Underlined nucleotides represent the overhang sequences formed after restriction enzyme cleavage. (b,c) Viral replication of SARS-CoV Urbani (black) or SHC014-CoV (green) after infection of Vero cells (b) or well-differentiated, primary air-liquid interface HAE cell cultures (c) at an MOI of 0.01. Samples were collected at individual time points with biological replicates (n = 3) for each group. Data represent one experiment for both Vero and HAE cells. (d,e) Weight loss (n = 3 for SARS-CoV MA15, n = 7 for SHC014-CoV; n = 6 for SARS-Urbani) (d) and viral replication in the lungs (n = 3 for SARS-Urbani and SHC014-CoV) (e) of 10-week-old BALB/c mice infected with 1 × 105 p.f.u. of SARS-CoV MA15 (gray), SHC014-CoV (green) or SARS-CoV Urbani (black) via the i.n. route. Each data point represents the group mean, and error bars define the s.e.m. **P < 0.01 and ***P < 0.001 using two-tailed Student’s t-test of individual time points.

During the SARS-CoV epidemic, links were quickly established between palm civets and the CoV strains that were detected in humans4. Building on this finding, the common emergence paradigm argues that epidemic SARS-CoV originated as a bat virus, jumped to civets and incorporated changes within the receptor-binding domain (RBD) to improve binding to civet Ace2 (ref. 18). Subsequent exposure to people in live-animal markets permitted human infection with the civet strain, which, in turn, adapted to become the epidemic strain (Fig. 4a). However, phylogenetic analysis suggests that early human SARS strains appear more closely related to bat strains than to civet strains18. Therefore, a second paradigm argues that direct bat-human transmission initiated SARS-CoV emergence and that palm civets served as a secondary host and reservoir for continued infection (Fig. 4b)19. For both paradigms, spike adaptation in a secondary host is seen as a necessity, with most mutations expected to occur within the RBD, thereby facilitating improved infection. Both theories imply that pools of bat CoVs are limited and that host-range mutations are both random and rare, reducing the likelihood of future emergence events in humans.

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Figure 4

Emergence paradigms for coronaviruses.

Coronavirus strains are maintained in quasi-species pools circulating in bat populations. (a,b) Traditional SARS-CoV emergence theories posit that host-range mutants (red circle) represent random and rare occurrences that permit infection of alternative hosts. The secondary-host paradigm (a) argues that a nonhuman host is infected by a bat progenitor virus and, through adaptation, facilitates transmission to humans; subsequent replication in humans leads to the epidemic viral strain. The direct paradigm (b) suggests that transmission occurs between bats and humans without the requirement of an intermediate host; selection then occurs in the human population with closely related viruses replicating in a secondary host, permitting continued viral persistence and adaptation in both. (c) The data from chimeric SARS-like viruses argue that the quasi-species pools maintain multiple viruses capable of infecting human cells without the need for mutations (red circles). Although adaptations in secondary or human hosts may be required for epidemic emergence, if SHC014 spike–containing viruses recombined with virulent CoV backbones (circles with green outlines), then epidemic disease may be the result in humans. Existing data support elements of all three paradigms.

Although our study does not invalidate the other emergence routes, it does argue for a third paradigm in which circulating bat CoV pools maintain ‘poised’ spike proteins that are capable of infecting humans without mutation or adaptation (Fig. 4c). This hypothesis is illustrated by the ability of a chimeric virus containing the SHC014 spike in a SARS-CoV backbone to cause robust infection in both human airway cultures and in mice without RBD adaptation. Coupled with the observation of previously identified pathogenic CoV backbones3,20, our results suggest that the starting materials required for SARS-like emergent strains are currently circulating in animal reservoirs. Notably, although full-length SHC014-CoV probably requires additional backbone adaption to mediate human disease, the documented high-frequency recombination events in CoV families underscores the possibility of future emergence and the need for further preparation.

To date, genomics screens of animal populations have primarily been used to identify novel viruses in outbreak settings21. The approach here extends these data sets to examine questions of viral emergence and therapeutic efficacy. We consider viruses with the SHC014 spike a potential threat owing to their ability to replicate in primary human airway cultures, the best available model for human disease. In addition, the observed pathogenesis in mice indicates a capacity for SHC014-containing viruses to cause disease in mammalian models, without RBD adaptation. Notably, differential tropism in the lung as compared to that with SARS-MA15 and attenuation of full-length SHC014-CoV in HAE cultures relative to SARS-CoV Urbani suggest that factors beyond ACE2 binding—including spike processivity, receptor bio-availability or antagonism of the host immune responses—may contribute to emergence. However, further testing in nonhuman primates is required to translate these finding into pathogenic potential in humans. Importantly, the failure of available therapeutics defines a critical need for further study and for the development of treatments. With this knowledge, surveillance programs, diagnostic reagents and effective treatments can be produced that are protective against the emergence of group 2b–specific CoVs, such as SHC014, and these can be applied to other CoV branches that maintain similarly heterogeneous pools.

In addition to offering preparation against future emerging viruses, this approach must be considered in the context of the US government–mandated pause on gain-of-function (GOF) studies22. On the basis of previous models of emergence (Fig. 4a,b), the creation of chimeric viruses such as SHC014-MA15 was not expected to increase pathogenicity. Although SHC014-MA15 is attenuated relative to its parental mouse-adapted SARS-CoV, similar studies examining the pathogenicity of CoVs with the wild-type Urbani spike within the MA15 backbone showed no weight loss in mice and reduced viral replication23. Thus, relative to the Urbani spike–MA15 CoV, SHC014-MA15 shows a gain in pathogenesis (Fig. 1). On the basis of these findings, scientific review panels may deem similar studies building chimeric viruses based on circulating strains too risky to pursue, as increased pathogenicity in mammalian models cannot be excluded. Coupled with restrictions on mouse-adapted strains and the development of monoclonal antibodies using escape mutants, research into CoV emergence and therapeutic efficacy may be severely limited moving forward. Together, these data and restrictions represent a crossroads of GOF research concerns; the potential to prepare for and mitigate future outbreaks must be weighed against the risk of creating more dangerous pathogens. In developing policies moving forward, it is important to consider the value of the data generated by these studies and whether these types of chimeric virus studies warrant further investigation versus the inherent risks involved.

Overall, our approach has used metagenomics data to identify a potential threat posed by the circulating bat SARS-like CoV SHC014. Because of the ability of chimeric SHC014 viruses to replicate in human airway cultures, cause pathogenesis in vivo and escape current therapeutics, there is a need for both surveillance and improved therapeutics against circulating SARS-like viruses. Our approach also unlocks the use of metagenomics data to predict viral emergence and to apply this knowledge in preparing to treat future emerging virus infections.

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Methods

Viruses, cells, in vitro infection and plaque assays.

Wild-type SARS-CoV (Urbani), mouse-adapted SARS-CoV (MA15) and chimeric SARS-like CoVs were cultured on Vero E6 cells (obtained from United States Army Medical Research Institute of Infectious Diseases), grown in Dulbecco’s modified Eagle’s medium (DMEM) (Gibco, CA) and 5% fetal clone serum (FCS) (Hyclone, South Logan, UT) along with antibiotic/antimycotic (Gibco, Carlsbad, CA). DBT cells (Baric laboratory, source unknown) expressing ACE2 orthologs have been previously described for both human and civet; bat Ace2 sequence was based on that from Rhinolophus leschenaulti, and DBT cells expressing bat Ace2 were established as described previously8. Pseudotyping experiments were similar to those using an HIV-based pseudovirus, prepared as previously described10, and examined on HeLa cells (Wuhan Institute of Virology) that expressed ACE2 orthologs. HeLa cells were grown in minimal essential medium (MEM) (Gibco, CA) supplemented with 10% FCS (Gibco, CA) as previously described24. Growth curves in Vero E6, DBT, Calu-3 2B4 and primary human airway epithelial cells were performed as previously described8,25. None of the working cell line stocks were authenticated or tested for mycoplasma recently, although the original seed stocks used to create the working stocks are free from contamination. Human lungs for HAE cultures were procured under University of North Carolina at Chapel Hill Institutional Review Board–approved protocols. HAE cultures represent highly differentiated human airway epithelium containing ciliated and non-ciliated epithelial cells as well as goblet cells. The cultures are also grown on an air-liquid interface for several weeks before use, as previously described26. Briefly, cells were washed with PBS and inoculated with virus or mock-diluted in PBS for 40 min at 37 °C. After inoculation, cells were washed three times and fresh medium was added to signify time ‘0’. Three or more biological replicates were harvested at each described time point. No blinding was used in any sample collections nor were samples randomized. All virus cultivation was performed in a biosafety level (BSL) 3 laboratory with redundant fans in the biosafety cabinets, as described previously by our group2. All personnel wore powered air purifying respirators (Breathe Easy, 3M) with Tyvek suits, aprons and booties and were double-gloved.

Sequence clustering and structural modeling.

The full-length genomic sequences and the amino acid sequences of the S1 domains of the spike of representative CoVs were downloaded from Genbank or Pathosystems Resource Integration Center (PATRIC), aligned with ClustalX and phylogenetically compared by using maximum likelihood estimation using 100 bootstraps or by using the PhyML (https://code.google.com/p/phyml/) package, respectively. The tree was generated using maximum likelihood with the PhyML package. The scale bar represents nucleotide substitutions. Only nodes with bootstrap support above 70% are labeled. The tree shows that CoVs are divided into three distinct phylogenetic groups defined as α-CoVs, β-CoVs and γ-CoVs. Classical subgroup clusters are marked as 2a, 2b, 2c and 2d for β-CoVs, and 1a and 1b for the α-CoVs. Structural models were generated using Modeller (Max Planck Institute Bioinformatics Toolkit) to generate homology models for SHC014 and Rs3367 of the SARS RBD in complex with ACE2 based on crystal structure 2AJF (Protein Data Bank). Homology models were visualized and manipulated in MacPyMol (version 1.3).

Construction of SARS-like chimeric viruses.

Both wild-type and chimeric viruses were derived from either SARS-CoV Urbani or the corresponding mouse-adapted (SARS-CoV MA15) infectious clone (ic) as previously described27. Plasmids containing spike sequences for SHC014 were extracted by restriction digest and ligated into the E and F plasmid of the MA15 infectious clone. The clone was designed and purchased from Bio Basic as six contiguous cDNAs using published sequences flanked by unique class II restriction endonuclease sites (BglI). Thereafter, plasmids containing wild-type, chimeric SARS-CoV and SHC014-CoV genome fragments were amplified, excised, ligated and purified. In vitro transcription reactions were then preformed to synthesize full-length genomic RNA, which was transfected into Vero E6 cells as previously described2. The medium from transfected cells was harvested and served as seed stocks for subsequent experiments. Chimeric and full-length viruses were confirmed by sequence analysis before use in these studies. Synthetic construction of chimeric mutant and full-length SHC014-CoV was approved by the University of North Carolina Institutional Biosafety Committee and the Dual Use Research of Concern committee.

Ethics statement.

This study was carried out in accordance with the recommendations for the care and use of animals by the Office of Laboratory Animal Welfare (OLAW), NIH. The Institutional Animal Care and Use Committee (IACUC) of The University of North Carolina at Chapel Hill (UNC, Permit Number A-3410-01) approved the animal study protocol (IACUC #13-033) used in these studies.

Mice and in vivo infection.

Female, 10-week-old and 12-month-old BALB/cAnNHsD mice were ordered from Harlan Laboratories. Mouse infections were done as previously described20. Briefly, animals were brought into a BSL3 laboratory and allowed to acclimate for 1 week before infection. For infection and live-attenuated virus vaccination, mice were anesthetized with a mixture of ketamine and xylazine and infected intranasally, when challenged, with 50 μl of phosphate-buffered saline (PBS) or diluted virus with three or four mice per time point, per infection group per dose as described in the figure legends. For individual mice, notations for infection including failure to inhale the entire dose, bubbling of inoculum from the nose, or infection through the mouth may have led to exclusion of mouse data at the discretion of the researcher; post-infection, no other pre-established exclusion or inclusion criteria are defined. No blinding was used in any animal experiments, and animals were not randomized. For vaccination, young and aged mice were vaccinated by footpad injection with a 20-μl volume of either 0.2 μg of double-inactivated SARS-CoV vaccine with alum or mock PBS; mice were then boosted with the same regimen 22 d later and challenged 21 d thereafter. For all groups, as per protocol, animals were monitored daily for clinical signs of disease (hunching, ruffled fur and reduced activity) for the duration of the experiment. Weight loss was monitored daily for the first 7 d, after which weight monitoring continued until the animals recovered to their initial starting weight or displayed weight gain continuously for 3 d. All mice that lost greater than 20% of their starting body weight were ground-fed and further monitored multiple times per day as long as they were under the 20% cutoff. Mice that lost greater than 30% of their starting body weight were immediately sacrificed as per protocol. Any mouse deemed to be moribund or unlikely to recover was also humanely sacrificed at the discretion of the researcher. Euthanasia was performed using an isoflurane overdose and death was confirmed by cervical dislocation. All mouse studies were performed at the University of North Carolina (Animal Welfare Assurance #A3410-01) using protocols approved by the UNC Institutional Animal Care and Use Committee (IACUC).

Histological analysis.

The left lung was removed and submerged in 10% buffered formalin (Fisher) without inflation for 1 week. Tissues were embedded in paraffin and 5-μm sections were prepared by the UNC Lineberger Comprehensive Cancer Center histopathology core facility. To determine the extent of antigen staining, sections were stained for viral antigen using a commercially available polyclonal SARS-CoV anti-nucleocapsid antibody (Imgenex) and scored in a blinded manner by for staining of the airway and parenchyma as previously described20. Images were captured using an Olympus BX41 microscope with an Olympus DP71 camera.

Virus neutralization assays.

Plaque reduction neutralization titer assays were performed with previously characterized antibodies against SARS-CoV, as previously described11,12,13. Briefly, neutralizing antibodies or serum was serially diluted twofold and incubated with 100 p.f.u. of the different infectious clone SARS-CoV strains for 1 h at 37 °C. The virus and antibodies were then added to a 6-well plate with 5 × 105 Vero E6 cells/well with multiple replicates (n ≥ 2). After a 1-h incubation at 37 °C, cells were overlaid with 3 ml of 0.8% agarose in medium. Plates were incubated for 2 d at 37 °C, stained with neutral red for 3 h and plaques were counted. The percentage of plaque reduction was calculated as (1 − (no. of plaques with antibody/no. of plaques without antibody)) × 100.

Statistical analysis.

All experiments were conducted contrasting two experimental groups (either two viruses, or vaccinated and unvaccinated cohorts). Therefore, significant differences in viral titer and histology scoring were determined by a two-tailed Student’s t-test at individual time points. Data was normally distributed in each group being compared and had similar variance.

Biosafety and biosecurity.

Reported studies were initiated after the University of North Carolina Institutional Biosafety Committee approved the experimental protocol (Project Title: Generating infectious clones of bat SARS-like CoVs; Lab Safety Plan ID: 20145741; Schedule G ID: 12279). These studies were initiated before the US Government Deliberative Process Research Funding Pause on Selected Gain-of-Function Research Involving Influenza, MERS and SARS Viruses (http://www.phe.gov/s3/dualuse/Documents/gain-of-function.pdf). This paper has been reviewed by the funding agency, the NIH. Continuation of these studies was requested, and this has been approved by the NIH.

SARS-CoV is a select agent. All work for these studies was performed with approved standard operating procedures (SOPs) and safety conditions for SARS-CoV, MERs-CoV and other related CoVs. Our institutional CoV BSL3 facilities have been designed to conform to the safety requirements that are recommended in the Biosafety in Microbiological and Biomedical Laboratories (BMBL), the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control (CDC) and the NIH. Laboratory safety plans were submitted to, and the facility has been approved for use by, the UNC Department of Environmental Health and Safety (EHS) and the CDC. Electronic card access is required for entry into the facility. All workers have been trained by EHS to safely use powered air purifying respirators (PAPRs), and appropriate work habits in a BSL3 facility and active medical surveillance plans are in place. Our CoV BSL3 facilities contain redundant fans, emergency power to fans and biological safety cabinets and freezers, and our facilities can accommodate SealSafe mouse racks. Materials classified as BSL3 agents consist of SARS-CoV, bat CoV precursor strains, MERS-CoV and mutants derived from these pathogens. Within the BSL3 facilities, experimentation with infectious virus is performed in a certified Class II Biosafety Cabinet (BSC). All members of the staff wear scrubs, Tyvek suits and aprons, PAPRs and shoe covers, and their hands are double-gloved. BSL3 users are subject to a medical surveillance plan monitored by the University Employee Occupational Health Clinic (UEOHC), which includes a yearly physical, annual influenza vaccination and mandatory reporting of any symptoms associated with CoV infection during periods when working in the BSL3. All BSL3 users are trained in exposure management and reporting protocols, are prepared to self-quarantine and have been trained for safe delivery to a local infectious disease management department in an emergency situation. All potential exposure events are reported and investigated by EHS and UEOHC, with reports filed to both the CDC and the NIH.

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Supplementary information

Supplementary Figures 1–6 and Supplementary Tables 1–4 (PDF 4747 kb)(4.6M, pdf)

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Acknowledgements

Research in this manuscript was supported by grants from the National Institute of Allergy & Infectious Disease and the National Institute of Aging of the US National Institutes of Health (NIH) under awards U19AI109761 (R.S.B.), U19AI107810 (R.S.B.), AI085524 (W.A.M.), F32AI102561 (V.D.M.) and K99AG049092 (V.D.M.), and by the National Natural Science Foundation of China awards 81290341 (Z.-L.S.) and 31470260 (X.-Y.G.), and by USAID-EPT-PREDICT funding from EcoHealth Alliance (Z.-L.S.). Human airway epithelial cultures were supported by the National Institute of Diabetes and Digestive and Kidney Disease of the NIH under award NIH DK065988 (S.H.R.). We also thank M.T. Ferris (Dept. of Genetics, University of North Carolina) for the reviewing of statistical approaches and C.T. Tseng (Dept. of Microbiology and Immunology, University of Texas Medical Branch) for providing Calu-3 cells. Experiments with the full-length and chimeric SHC014 recombinant viruses were initiated and performed before the GOF research funding pause and have since been reviewed and approved for continued study by the NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Author Contributions

V.D.M. designed, coordinated and performed experiments, completed analysis and wrote the manuscript. B.L.Y. designed the infectious clone and recovered chimeric viruses; S.A. completed neutralization assays; L.E.G. helped perform mouse experiments; T.S. and J.A.P. completed mouse experiments and plaque assays; X.-Y.G. performed pseudotyping experiments; K.D. generated structural figures and predictions; E.F.D. generated phylogenetic analysis; R.L.G. completed RNA analysis; S.H.R. provided primary HAE cultures; A.L. and W.A.M. provided critical monoclonal antibody reagents; and Z.-L.S. provided SHC014 spike sequences and plasmids. R.S.B. designed experiments and wrote manuscript.

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Accession codes

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Accessions

Protein Data Bank

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Competing interests

The authors declare no competing financial interests.

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Contributor Information

Vineet D Menachery, Email: ude.cnu.liame@teeniv.

Ralph S Baric, Email: ude.cnu.liame@cirabr.

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Covid-19 secret is with Baric, Daszak and Zhengli Who Did the Gain of Function and Baric Later the NoSeeUm Coverup. Great evil perpetrators, for Pentagon.

March 20, 2023

Quote Dr. David Martin said Peter Daszak wrote in 2015 ‘they needed the media to hype up the need for coronavirus vaccines to sell them’. The very next year Dr Ralf Baric wrote in 2016: ‘..’the (WIV) virus was human ready’ a clear indication a weapon was being readied for human transmission. Seems to me J. Jyrkkanen ‘Collusion and Conspiracy to commit a crime for profit’.

These folks woked together with a large team under the funding of Fauci, the Government and even President Biden to craft a deadly population whacking killer bioweapon and even created technology to hide the fact. The NoSeeUm Technology of Baric.

(Left to right): Ralph Baric, Peter Daszak, Shi Zhengli.

A group of Chinese scientists lobbied to rename ‘SARS-CoV-2’ to ‘2019-nCoV’. In the correspondence, the scientists feared that the virus would become known as ‘Wuhan Coronavirus’ or ‘Wuhan Pneumonia’.

The truth behind the science around the origin of the SARS-CoV-2 lies with Ralph Baric of the University of North Carolina, Peter Daszak of EcoHealth Alliance and Prof Shi Zhengli of the Wuhan Institute of Virology (WIV).

According to the email obtained by the US Right To Know organization, on January 13, 2020, in an email to Peter Daszak at 6.50 pm, Ralph Baric, states:

“Hi Peter, I have to participate in an NIH call tomorrow at 10. I believe it’s a strategic meeting designed to help craft a NIH response plan to the WU-CoV. Hope things are going well. Looks like we found our highly variable SARS-like CoV! Ralph”

In reply to Ralph Baric’s email, Peter Daszak at 7.55 pm states:

“It sounds like we’re on the same call! And my exact thoughts are of the highly variable SARS-like CoV. I’ve told journalists about it, but it’s a complicated story for them to get across.”

On 13 January 2020, before China or the World Health Organisation (WHO) made any official statement on the nature of the coronavirus, both Ralph Baric and Peter Daszak in their emails appear to be confident that the coronavirus in China is a “highly variable SARS-like CoV”. Most importantly, Ralph Baric refers to the coronavirus as “Our highly variable SARS-like COV”, displaying a familiarity with the virus.

Reportedly, in 2013, the American virologist Ralph Baric approached Zhengli Shi at a meeting. Shi had detected the genome of a new virus, called SHC014, that was one of the two closest relatives to the original SARS virus, but her team had not been able to culture it in the laboratory. Baric had developed a way around that problem—a technique termed as “reverse genetics” in coronaviruses. Not only did it allow him to bring an actual virus to life from its genetic code, but he could mix and match parts of multiple viruses. He wanted to take the “spike” gene from SHC014 and move it into a genetic copy of the SARS virus he already had in his laboratory. The spike molecule is what lets a coronavirus open a cell and get inside it. The resulting chimera would demonstrate whether the spike of SHC014 would attach to human cells.

Baric asked Shi Zhengli if he could have the genetic data for SHC014. “She was gracious enough to send us those sequences almost immediately,” he told media. His team introduced the virus modified with that code into mice and into a petri dish of human airway cells. Sure enough, the chimera exhibited “robust replication” in the human cells—evidence that nature was full of coronaviruses ready to leap directly to people.

It is no surprise that a group of Chinese scientists lobbied through US Professor of the University of North Carolina Ralph Baric to rename «SARS-CoV-2» given by the Coronavirus Study Group (CSG) of the International Committee on Virus Taxonomy (ICTV) to “2019-nCoV”. In the correspondence, the Chinese scientists feared that the virus would become known as “Wuhan Coronavirus” or “Wuhan Pneumonia”. In an email dated 13/2/2020, Professor Shi Zhengli wrote to Ralph Baric. The subject of the email was “Virus Name”. The email had an attached document titled, “A unique and unified name for the novel coronavirus from Wuhan SJ clean”.

The email stated:

“Dear Ralph,

We heard that the 2019-nCoV was renamed as SARS-CoV-2. We had a fierce discussion among Chinese virologists. We have some comments on this name, I’m wondering if the CoV study group would consider a revision.

I attached the comments from me and my Chinese colleague.”

The document from Prof. Shi Zhengli to Prof. Ralph Baric states:

“A unique and unified name is needed for the novel coronavirus identified from Wuhan. An outbreak of unusual pneumonia of unknown cause in Wuhan, China, was first reported in December 2019. By 5 January 2020, Chinese scientists had quickly identified the causative agent a new type of coronavirus (CoV) belonging to the Betacoronaviruses genus of the Coronavirdae family that also includes severe acute respiratory syndrome (SARS)-CoV and the Middle East respiratory syndrome (MERS)- CoV.

On 12 January 2020, the World Health Organization (WHO) temporarily named the virus as 2019 novel coronavirus (2019-nCoV). On 30 January, WHO recommended naming the disease as “2019-nCoV acute respiratory disease”. On 8 February 2020, the China National Health Commission (CNHC) announced naming the disease as “Novel CoronavirusPneumonia” (NCP). On 11 February 2020, WHO renamed the disease “coronavirus disease2019” (COVID-19). On 7 February 2020, the Coronavirus Study Group (CSG) of the International Committee on Virus Taxonomy (ICTV) posted a manuscript at bioRxiv and suggested designating the novel coronavirus as “severe acute respiratory syndrome coronavirus 2(SA RS-CoV-2)” based on the phylogenetic analysis of related coronaviruses.

Zhengli further in her document to Ralph Baric says, “By 11th February 2020, the new coronavirus had caused more than 40,000 confirmed infections and more than 1000 deaths, mostly in mainland China, despite efforts by the Chinese government and its people to contain the spread of the virus in past weeks. lt goes without saying that the effects of the epidemic on all the aspects of Chinese life are devastating and, possibly, irreversible. Consequently, appropriately naming the virus and disease becomes a matter of importance to the Chinese people, in general, and virologists, in specific, and the issue has been fervently discussed and debated among scientists with the outcome, so far, as noted above. We fully agree that the new virus and SARS-CoV belong to the same virus species by classification. However, the consensus opinion of Chinese virologists is that none of the currently proposed names reflects the uniqueness and characteristics of the novel virus and that more consideration is needed for naming the virus. Based on the following reasons, we propose giving a unique and unified name to the new virus.”

Prof Shi Zhengli, also known as the “Batwoman”, continues to impress upon Ralph Baric on behalf of the group of Chinese scientists. She says, “All proposed names are either too generic, or too similar, to previously well-known viruses, or contain an Arabic number. This makes it hard to remember or recognize, leading to a tendency among the general population and scientists alike to use a shorthand term such as ‘Wuhan coronavirus’ or ‘Wuhan pneumonia’. This has, in fact. been the case since it was named as 2019-nCoV. This practice would, however, stigmatize and insult the people in Wuhan, who are still suffering from the outbreak.”

The document sent by Prof Zhengli to Ralph Baric, further states, “The new virus is still evolving, and it is still too early to predict the outcome of the current outbreak. However, it is already clear that the infection of the new virus has diverse symptoms, from asymptomatic infection to severe pneumonia and even death. It has less case-fatality rate and higher transmissibility than SARS-CoV, indicating its clear difference from SARS-CoV. Again. therefore, it is not appropriate to designate the new virus as SARS-CoV-2 before we know more properties of the virus.”

Baric, Daszak and Zhengli were working together on the gain-of-function research. Scientists have posited that SARS-CoV-2 may be a product of WIV’s experiments on an unpublished bat coronavirus that is more closely related to SARS-CoV-2 than RaTG13. “First, SARS-CoV-2 may have evolved in bats, which are known reservoirs of immense coronavirus diversity, and then spread directly, or indirectly via an intermediate host, to humans through natural mechanisms. The degree of anticipated but undiscovered natural diversity clearly lends support to this scenario, as well as support to other scenarios. Second, SARS-CoV-2 or a recent ancestor virus may have been collected by humans from a bat or other animal and then brought to a laboratory where it was stored knowingly or unknowingly, propagated and perhaps manipulated genetically to understand its biological properties and then released accidentally.“

Wuhan Institute of Virology authorities shut down outside access to its virus database in September 2019, thereby making it difficult to verify that “The Wuhan lab has many bat samples not yet worked out or results published. There are some concerns that some of their samples may not have been handled properly and leaked out of the lab.”

Savio Rodrigues is the founder and editor-in-chief of Goa Chronicle.

NATURE MEDICINE PUBLICATION FOLLOWS

naturenews

  1. article

Engineered bat virus stirs debate over risky research 

Nature (2015)Cite this article

Lab-made coronavirus related to SARS can infect human cells.

An experiment that created a hybrid version of a bat coronavirus — one related to the virus that causes SARS (severe acute respiratory syndrome) — has triggered renewed debate over whether engineering lab variants of viruses with possible pandemic potential is worth the risks.

In an article published in Nature Medicine1 on 9 November, scientists investigated a virus called SHC014, which is found in horseshoe bats in China. The researchers created a chimaeric virus, made up of a surface protein of SHC014 and the backbone of a SARS virus that had been adapted to grow in mice and to mimic human disease. The chimaera infected human airway cells — proving that the surface protein of SHC014 has the necessary structure to bind to a key receptor on the cells and to infect them. It also caused disease in mice, but did not kill them.

Although almost all coronaviruses isolated from bats have not been able to bind to the key human receptor, SHC014 is not the first that can do so. In 2013, researchers reported this ability for the first time in a different coronavirus isolated from the same bat population2.

The findings reinforce suspicions that bat coronaviruses capable of directly infecting humans (rather than first needing to evolve in an intermediate animal host) may be more common than previously thought, the researchers say.

But other virologists question whether the information gleaned from the experiment justifies the potential risk. Although the extent of any risk is difficult to assess, Simon Wain-Hobson, a virologist at the Pasteur Institute in Paris, points out that the researchers have created a novel virus that “grows remarkably well” in human cells. “If the virus escaped, nobody could predict the trajectory,” he says.

Creation of a chimaera

The argument is essentially a rerun of the debate over whether to allow lab research that increases the virulence, ease of spread or host range of dangerous pathogens — what is known as ‘gain-of-function’ research. In October 2014, the US government imposed a moratorium on federal funding of such research on the viruses that cause SARS, influenza and MERS (Middle East respiratory syndrome, a deadly disease caused by a virus that sporadically jumps from camels to people).

The latest study was already under way before the US moratorium began, and the US National Institutes of Health (NIH) allowed it to proceed while it was under review by the agency, says Ralph Baric, an infectious-disease researcher at the University of North Carolina at Chapel Hill, a co-author of the study. The NIH eventually concluded that the work was not so risky as to fall under the moratorium, he says.

But Wain-Hobson disapproves of the study because, he says, it provides little benefit, and reveals little about the risk that the wild SHC014 virus in bats poses to humans.

Other experiments in the study show that the virus in wild bats would need to evolve to pose any threat to humans — a change that may never happen, although it cannot be ruled out. Baric and his team reconstructed the wild virus from its genome sequence and found that it grew poorly in human cell cultures and caused no significant disease in mice.

“The only impact of this work is the creation, in a lab, of a new, non-natural risk,” agrees Richard Ebright, a molecular biologist and biodefence expert at Rutgers University in Piscataway, New Jersey. Both Ebright and Wain-Hobson are long-standing critics of gain-of-function research.

In their paper, the study authors also concede that funders may think twice about allowing such experiments in the future. “Scientific review panels may deem similar studies building chimeric viruses based on circulating strains too risky to pursue,” they write, adding that discussion is needed as to “whether these types of chimeric virus studies warrant further investigation versus the inherent risks involved”.

Useful research

But Baric and others say the research did have benefits. The study findings “move this virus from a candidate emerging pathogen to a clear and present danger”, says Peter Daszak, who co-authored the 2013 paper. Daszak is president of the EcoHealth Alliance, an international network of scientists, headquartered in New York City, that samples viruses from animals and people in emerging-diseases hotspots across the globe.

Studies testing hybrid viruses in human cell culture and animal models are limited in what they can say about the threat posed by a wild virus, Daszak agrees. But he argues that they can help indicate which pathogens should be prioritized for further research attention.

Without the experiments, says Baric, the SHC014 virus would still be seen as not a threat. Previously, scientists had believed, on the basis of molecular modelling and other studies, that it should not be able to infect human cells. The latest work shows that the virus has already overcome critical barriers, such as being able to latch onto human receptors and efficiently infect human airway cells, he says. “I don’t think you can ignore that.” He plans to do further studies with the virus in non-human primates, which may yield data more relevant to humans.

References

  1. Menachery, V. D. et al. Nature Med. http://dx.doi.org/10.1038/nm.3985 (2015).
  2. Ge, X.-Y. et al. Nature 503, 535–538 (2013).

Geopolitical Consequence of the WIV Collaboration

https://jyrkkanenepigeneticsnews.wordpress.com/2024/01/20/chinese-create-100-lethal-covid-in-humanized-mice-repost-2024-01-20-jorma-jyrkkanen-analyst/

Where Covid Started and by Whom. Ukraine Labs Also Accused by Russia for Participation. 2023-07-03

March 16, 2023

Quote Dr. David Martin said Peter Daszak wrote in 2015 ‘they needed the media to hype up the need for coronavirus vaccines to sell them’. The very next year Dr Ralf Baric wrote in 2016: ‘..’the (WIV) virus was human ready’ a clear indication a weapon was being readied for human transmission. Seems to me J. Jyrkkanen ‘Collusion and Conspiracy to commit a crime for profit’.

·

@jimmy_dore

: “They took the money that Cheney gave them [from the Patriot Act], $2.2 billion, and they funneled it through NIH, and it all went through Anthony Fauci. So beginning in 2002, Anthony Fauci got a 68% raise from the Pentagon for doing bioweapons development, and he got a raise of billions of dollars a year, and then he started doing all of this gain-of-function. In 2014, three of those bugs escaped in high-profile escapes from different labs in the US. Congress held hearings on it. Everybody was angry, and 300 top scientists sent letters to Obama saying you got to shut down Fauci because he is going to create a pandemic. So, Obama ordered a moratorium, and at that time, Fauci had eighteen different gain-of-function experiments he was doing around the US. He instead moved his stuff offshore to Wuhan, where he could do it out of sight of these 300 scientists and nosy White House officials who were trying to shut him down. And he continued to do it with the same people he was funding here, Ralph Baric and Peter Dazak, and they moved their operation to the Wuhan lab.”

3 Big Problems with the Sars 2 covid-19 Pandemic.

Fauci Funded Seamless Ligation ‘noseeum’ technology Development by Ralf Baric an N. Carolina U to Hide Virus Tampering. Evil Genius.

March 14, 2023

.

@RobertKennedyJr

tells

@jimmy_dore

the CIA, DOD, and Tony Fauci taught Chinese military scientists how to build weapons of mass destruction. Then Bill Gates, a former CIA director, and China’s CDC director collaborated on how to censor a lab leak at Event 201 in Oct. 2019:

“Fauci funded the study that taught the Chinese military scientists, everything in China is dual-use, that lab is a military lab, and he taught them cutting-edge technology for building weapons of mass destruction.

In other words, the study for how to create the clones and how to create a spike protein that could attach to a human lung and transplant it onto a coronavirus.

He also funded through Ralph Baric at the University of North Carolina a technique called seamless ligation which is a technique for hiding human tampering on that virus after you’ve done it. Fauci gave Baric $212 million, and Baric developed a technique for hiding the human tampering; (Pic)

Quote Dr. David Martin said Peter Daszak wrote in 2015 ‘they needed the media to hype up the need for coronavirus vaccines to sell them’. The very next year Dr Ralf Baric wrote in 2016: ‘..’the (WIV) virus was human ready’ a clear indication a weapon was being readied for human transmission. Seems to me J. Jyrkkanen ‘Collusion and Conspiracy to commit a crime for profit’.

Baric taught that to Shi Zhengli (BELOW), the Chinese bat lady. Fauci says we were doing this for vaccine development and countermeasures, but there is no justification in the world for funding somebody to create seamless ligation; in fact, it is the inverse of what you would do if your interest was public health. If your interest was bioweapons creation, and he was the czar of bioweapons since 2002, that’s what you would do. USAID gave ten times what Fauci gave. The DOD was there. Why were they in there teaching Chinese scientists how to build weapons of mass destruction?

USAID is a CIA front group. Eco-health Alliance is a CIA front group. The CIA modeled this outbreak in 2019 twice, the second time at Event 201. Who was at Event 201? Avril Haines co-hosted it with Bill Gates, and the head of the Chinese CDC, George Gao, was there. The virus was already circulating in Wuhan, nobody knew it, but George Gao had to know it; he was the head of the Chinese CDC and their number one expert on coronaviruses. He comes to New York in October of 2019 and sits downs with Avril Haines, the former director of the CIA, today the Director of National Intelligence, the top spy in the country, and they do a four-part simulation, and the fourth part is George Gao and Avril Haines talking about how do we get social media to censor people if they say this is from a lab leak.”

#SpartaJustice Calls for Arrests of Pandemic Conspirators

March 13, 2023

https://twitter.com/i/status/1633210206262894592

Truth Justice ™

@SpartaJustice

BREAKING NEWS:

Emergency injunction and tribunal order was served to WHO and all Criminal Defendants listed below to immediately cease and desist a criminal conspiracy to commit war crimes, genocide, crimes against humanity and to arrest and incarcerate these criminal defendants.

All Constitutional law enforcements officers worldwide are being served starting with Interpol and constitutional law enforcements in everyone of the 194 member nations under Writs of Mandamus ordering them to carry out their duties to arrest and incarcerate these criminal codefendants for unlawful and Genocidal acts in connection with the WHO Pandemic preparedness response and changes to the international health regulations.

Tribunal Writs of Mandamus is defined as: “The lawful term writ of mandamus refers to an order by a court to a lesser government official to perform an act required by law, which he has refused or neglected to do.

This type of court order is a remedy that may be sought if a governmental agency, public authority, or corporation in service of the government, fails or refuses to do its public or statutory duty.” This has been ordered by the Tribunal Under Articles 6 (Genocide) and 7 (Crimes Against Humanity) of the International Criminal Code.

List of Criminal Defendants 2009-2023 Lockstep Vaccination Genocidal Pandemic Criminal Co-conspiracy, including and not limited to individually and collectively:

Bill and Melinda Gates individually and the Bill and Melinda Gates Foundation.

World Health Organization (WHO) and Officers, Directors, Employees, and Agents Tedros Adhanom Ghebreyesus WHO Director General, Anthony Stephen Fauci.

World Economic Forum, Klaus Schwab and Officers, Directors, Employees, and Agents. Michael Bloomberg, David Rockefeller Jr, Warren Buffett, George Soros, Ted Turner, Oprah Winfrey, Rockefeller Foundation, Global Business Network (GBN), Peter Schwartz, Chairman GBN. Convicted Vaccination Genocidal Pandemic and Neural Monitoring Governmental Executive Defendants: Xi Jin

Ping, General Secretary of the Communist Party. Vladimir Vladimirovich Putin, President of the Russian Federation. Donald J. Trump, 45th President of the United States of America. Joseph R. Biden 46th President of the United States of America. Benjamin Netanyahu, Prime Minister of Israel. Boris Johnson, Prime Minister of the UK. Matt Hancock, UK Secretary of State for Health. The Crown Corporation and any and all of its Subsidiaries including and not limited to Serco. Justin Trudeau, Prime Minister of Canada. Scott Morrison, Prime Minister of Australia. Jacinda Arden, Prime Minister of New Zealand. Stefan Löfven Prime Minister of Sweden. Minister of Heath Lena Hallengren. Narendra Modi, Prime Minister of India. Emmanuel Jean-Michel Frédéric Macron, President of France. Edouard Phillipe, Prime Minister of France. Angela Merkel, Chancellor of Germany. António Guterres, Secretary General of the United Nations Organization. European Union, and President of the Commission, Ursula von der Leyen. President of the Parliament, David Sassoli. President of the European Council, Charles Michel. Michael Ryan,

WHO CEO’s at GCHQ-UK, NSA-USA and Bilderberg Group, all CEOs, Monarchies, and Members. Convicted Defendant Pandemic Vaccine Programs: Global Alliance Vaccine Initiative [GAVI], The Vaccine Alliance, including and not limited to its Pandemic Vaccine Program. Pandemic Vaccine Program United States of America, Operation Warp Speed and successor Pandemic Vaccine Program. World Health Organization COVAX, Pandemic Vaccine Program. Pandemic Vaccine Program People’s Republic of China, National Institutes for Food and Drug Control. Russian Federation, Rospotrebnadzor. Convicted Genocidal Vaccination Entities: Pfizer, AstraZeneca, Moderna, Johnson and Johnson, The Pirbright Institute.

02/24/23 Judge Pascal Najadi: They will all be arrested as soon as possible, Military and law enforcement worldwide are preparing for this to happen. Godspeed.

YOUR TV IS A LISTENING DEVICE FOR CIA AND YOUR VEHICLE CAN BE CONTROLLED TO KILL YOU

March 11, 2023

https://www.cbsnews.com/news/cia-hacked-samsung-smart-tvs-wikileaks-vault-7/

House Oversight Committee on Origin of the Covid Pandemic Link to Wuhan Lab. 2023-03-09. Jorma Jyrkkanen.

March 9, 2023

COVID Origins Hearing Wrap Up: Facts, Science, Evidence Point to a Wuhan Lab Leak

WASHINGTON—The Select Subcommittee on the Coronavirus Pandemic held a hearing on “Investigating the Origins of COVID-19” to gather facts about the origination of the virus that has claimed nearly seven million lives globally. At the hearing, several of the witnesses pointed to how the science, facts, and evidence point to a lab leak in Wuhan.

Key Hearing Takeaways

Knowing the origin of COVID-19 is fundamental to helping predict and prevent future pandemics.

Select Subcommittee Chairman Brad Wenstrup opened the hearing by emphasizing how knowing the origin of the virus is essential to helping predict and prevent future pandemics, protecting health and national security, and preparing the United States for the future. He pledged that the Select Subcommittee will thoroughly, responsibly, and honestly investigate the origin of COVID-19.

Dr. Jamie Metzl, Ph.D., senior fellow at the Atlantic Council said in an opening statement, “If we do not get to the bottom of what went wrong with the COVID-19 pandemic, if we fail in our efforts to fearlessly understand all shortcomings and shore up the vulnerabilities this crisis has so clearly exposed, the victims of the next pandemic, our children and grandchildren, will ask us why we failed to protect when we knew what was at stake and had the chance.”

Mounting evidence continues to show that COVID-19 may have originated from a lab in Wuhan, China.

Dr. Robert Redfield, former director of the U.S. Centers for Disease Control and Prevention (CDC), testified how science indicates COVID-19 infections were likely the result of an accidental lab leak in Wuhan. His conclusion is based on the biology of the virus itself and unusual actions in and around Wuhan in 2019, including gain-of-function research at the Wuhan Institute of Virology (WIV).

Nicholas Wade—the former science and health editor at the New York Times, and former editor of Science and Naturetestified how Drs. Fauci and Collins used unverified data to dismiss the lab leak theory in favor of natural transmission.

Jamie Metzl testified how China’s government destroyed samples, hid records, imprisoned Chinese journalists, prevented Chinese scientists from saying or writing anything on pandemic origins without prior government approval, actively spread misinformation, and prevented an evidence-based investigation.

The mainstream media downplayed—and even denied—the scientific theory that COVID-19 emerged from the WIV.

Nicholas Wade testified about the campaign to discredit the lab leak theory. He pointed out that scientists kept in line with the natural origin camp led by Drs. Fauci and Collins because of their dependence on government grants and that the media failed to challenge the forced narrative.

All witnesses agreed that the possibility of COVID-19 originating from a lab is not a conspiracy theory.

Member Highlights

Subcommittee Chairman Dr. Wenstrup (R-Ohio.) asked witnesses whether it is critical to investigate the origin of COVID-19. All witnesses answered yes. Chairman Wenstrup also raised concern about gain-of-function research, which Dr. Redfield defined during the hearing as altering a pathogen to increase either transmissibility or pathogenicity.

Subcommittee Chairman Wenstrup: “In your expert opinion was the Wuhan Institute conducting gain-of-function research on a batch of coronaviruses?”

Dr. Redfield: “Absolutely.”

Rep. Nicole Malliotakis (R-N.Y.) noted that after raising concerns to experts and the World Health Organization that COVID-19 may have originated in a lab in Wuhan, China, and urging Dr. Fauci to investigate the origins of the pandemic, Dr. Redfield was excluded from calls related to the origins of the pandemic.

Rep. Malliotakis: “Why do you think you were excluded from those calls?”

Dr. Redfield: “It was told to me that they wanted a single narrative and that I obviously had a different point of view.”

Dr. Redfield added: “If you really want to be truthful, it’s antithetical to science. Science has debate, and they squashed any debate.”

Scientists, including Dr. Fauci, then drafted a paper arguing COVID-19’s proximal origins to animals at a wet market.

Rep. Malliotakis: “Do you think that this paper does hide the truth?”

Dr. Redfield: “I think it’s an inaccurate paper that basically was part of a narrative that they were creating.”

Rep. Malliotakis also warned that the National Institutes of Health (NIH) may have been funding gain-of-function research on coronaviruses at the WIV.

Rep. Malliotakis: “Is it likely that American tax dollars funded the gain-of-function research that created this virus?”

Dr. Redfield: I think it did, not only from NIH, but from the State Department, USAID and DOD.”

Rep. Miller-Meeks (R-Iowa), who has expertise publishing in peer-reviewed scientific journals, asked why the scientific community dangerously suppressed evidence that COVID-19 may have originated from a lab.

“There is, as you said Dr. Metzl, extraordinary circumstantial evidence that this came from a lab. 

“I don’t know why the authors didn’t want to state this, they did not want to have the scientific conversation and dialogue, why they wanted to obfuscate and suppress the truth, or even have a debate about the origins of COVID-19.

“Was it for personal financial gain? Was it to hide U.S. financial interest into the Wuhan Institute of Virology indirectly? Was it to suppress the revelation that there was perhaps gain-of-function research that had been prohibited in the United States? Or were they concerned that a conspiracy would develop that it was bioterrorism?

“I would state that their suppression and obfuscation has led to the exact mistrust and conspiracy theories that they may have tried to avoid.”

Rep. Debbie Lesko (R-Colo.) and Dr. Redfield discussed unusual actions at the WIV in September 2019.

Rep. Lesko: “Do you believe we can have certainty that the virus did not come from the Wuhan lab and that U.S. funding was not used for coronavirus research?”

Dr. Redfield: “Absolutely we cannot do that. It’s now declassified now, but in September 2019, three things happened in that lab. One, they deleted the sequences. That is highly irregular—researchers don’t usually like to do that. Second, they commanded the command and control of the lab from civilian control to military control. Highly unusual. And the third thing they did, which I think is really telling, is they let a contractor re-do the ventilation system in that laboratory. There is strong evidence there was a significant event in that laboratory in September 2019.”

Oversight Committee Chairman James Comer (R-Ky.) warned that the media downplayed, discredited, and silenced voices of experts sounding the alarm that COVID-19 may have originated from a lab in Wuhan, China.

Chairman Comer: “Would you agree that the scientific establishment used the media to downplay the lab leak theory?”

Mr. Wade: “I think the media was used in this particular campaign to establish the natural origin theory.

“The scientific community is very afraid to speak up on political issues. I think the reason is that government grants are handed out through the system of peer-reviewed committees. You don’t want any single scientist on your peer-review committee to vote against, because you won’t get your grant – it’s so competitive. Therefore, scientists are very reluctant to say anything that’s politically divisive or turn other scientists off against them. This means that they cannot be relied upon in the way that we would like them to be independent and forthright and call it as they see it.”

Comer: “Was there science available to make such an unequivocal statement against the possibility of a lab leak that early on in February of 2020?”

Witnesses Dr. Metzl, Mr. Wade, and Dr. Redfield all answered, “No.”

Comer: “Is the possibility COVID-19 leaked from a lab a conspiracy theory?”

Witnesses answered, “No.”

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COVID-19–Associated cardiac pathology at the postmortem evaluation: a collaborative systematic review. Repost by J. Jyrkkanen. 2023-03-03

March 3, 2023

Almamlouk R, Kashour T, Obeidat S, Bois MC, Maleszewski JJ, Omrani OA, Tleyjeh R, Berbari E, Chakhachiro Z, Zein-Sabatto B, Gerberi D, Tleyjeh IM; Cardiac Autopsy in COVID-19 Study Group; Paniz Mondolfi AE, Finn AV, Duarte-Neto AN, Rapkiewicz AV, Frustaci A, Keresztesi AA, Hanley B, Märkl B, Lardi C, Bryce C, Lindner D, Aguiar D, Westermann D, Stroberg E, Duval EJ, Youd E, Bulfamante GP, Salmon I, Auer J, Maleszewski JJ, Hirschbühl K, Absil L, Barton LM, Ferraz da Silva LF, Moore L, Dolhnikoff M, Lammens M, Bois MC, Osborn M, Remmelink M, Nascimento Saldiva PH, Jorens PG, Craver R, Aparecida de Almeida Monteiro R, Scendoni R, Mukhopadhyay S, Suzuki T, Mauad T, Fracasso T, Grimes Z. COVID-19-Associated cardiac pathology at the postmortem evaluation: a collaborative systematic review. Clin Microbiol Infect. 2022 Aug;28(8):1066-1075. doi: 10.1016/j.cmi.2022.03.021. Epub 2022 Mar 23. PMID: 35339672; PMCID: PMC8941843.

Abstract

Background

Many postmortem studies address the cardiovascular effects of COVID-19 and provide valuable information, but are limited by their small sample size.

Objectives

The aim of this systematic review is to better understand the various aspects of the cardiovascular complications of COVID-19 by pooling data from a large number of autopsy studies.

Data sources

We searched the online databases Ovid EBM Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science for concepts of autopsy or histopathology combined with COVID-19, published between database inception and February 2021. We also searched for unpublished manuscripts using the medRxiv services operated by Cold Spring Harbor Laboratory.

Study eligibility criteria

Articles were considered eligible for inclusion if they reported human postmortem cardiovascular findings among individuals with a confirmed SARS coronavirus type 2 (CoV-2) infection.

Participants

Confirmed COVID-19 patients with post-mortem cardiovascular findings.

Interventions

None.

Methods

Studies were individually assessed for risk of selection, detection, and reporting biases. The median prevalence of different autopsy findings with associated interquartile ranges (IQRs).

Results

This review cohort contained 50 studies including 548 hearts. The median age of the deceased was 69 years. The most prevalent acute cardiovascular findings were myocardial necrosis (median: 100.0%; IQR, 20%–100%; number of studies = 9; number of patients = 64) and myocardial oedema (median: 55.5%; IQR, 19.5%–92.5%; number of studies = 4; number of patients = 46). The median reported prevalence of extensive, focal active, and multifocal myocarditis were all 0.0%. The most prevalent chronic changes were myocyte hypertrophy (median: 69.0%; IQR, 46.8%–92.1%) and fibrosis (median: 35.0%; IQR, 35.0%–90.5%). SARS-CoV-2 was detected in the myocardium with median prevalence of 60.8% (IQR 40.4-95.6%).

Conclusions

Our systematic review confirmed the high prevalence of acute and chronic cardiac pathologies in COVID-19 and SARS-CoV-2 cardiac tropism, as well as the low prevalence of myocarditis in COVID-19.

Keywords: Cardiac pathology, COVID-19, Myocarditis, Postmortem, SARS-CoV-2, Systematic review

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Introduction

Preexisting cardiovascular comorbidities are prevalent among patients with COVID-19 and associated with a higher mortality rate [[1], [2], [3]]. For example, in the study reported by the Chinese Centre for Disease Control and Prevention describing the early experience with the epidemic in the Hubie province, patients with cardiovascular comorbidities had a case fatality rate of 10.5% compared with an overall cohort fatality rate of 2.3% [4]. There is also emerging robust evidence to suggest long-term cardiovascular sequalae after acute COVID-19 infection with an increased risk of incident conditions, including dysrhythmias, ischemic and nonischemic heart disease, myocarditis, and thromboembolic disease, among different COVID-19 disease severity groups compared with patients not infected with COVID-19 [5].

In addition, echocardiographic studies in populations infected with COVID-19 have demonstrated a high prevalence of ventricular dysfunction. In a prospective international study of 1216 patients with COVID-19, overall left and right ventricular dysfunction were reported in 39% and 33%, respectively [6]. Even in patients without preexisting cardiac disease, abnormal echocardiographic findings were evident in 46% of patients, with 13% manifesting severe abnormalities [6]. Acute myocardial injury manifesting as an elevation in cardiac troponins has been reported in 7% to 28% of patients with COVID-19 [[7], [8], [9], [10]]. Such acute cardiac injury was associated with higher overall mortality [10]. In a meta-analysis of 13 studies, the risk of death was high among patients with COVID-19 who had acute myocardial injury as defined by elevated serum troponins (risk ratio: 7.95; CI, 5.12–12.34; p <0.001; I2 = 65%) [11].

Several mechanisms have been proposed to explain acute myocardial injury and ventricular dysfunction in patients with COVID-19, including supply–demand mismatch secondary to hypoxemia and elevated cardiac demand, direct damage inflicted by inflammatory cytokines, microvascular dysfunction, myocarditis, coagulation abnormalities, and coronary artery plaque instability [12,13]. Other proposed mechanisms, such as vasospasm, microvascular thrombosis, and myocarditis, could be responsible for the ST-segment elevation [14].

A direct pathologic cardiovascular examination of decedents provides important information about the true frequency of cardiac complications among patients with COVID-19, and sheds light on possible pathologic mechanisms. Early on, small postmortem studies described evidence of myocardial inflammation associated with myocyte necrosis in patients with COVD-19 [15,16], as well as a possible direct SARS coronavirus type 2 (CoV-2) infection of the heart [17]. Moreover, nonspecific longstanding findings, such as cardiac hypertrophy and fibrosis, suggest underlying cardiovascular disease in a subset of these patients. Multiple subsequent studies have been published with varying sample sizes, methodologies, and findings. These studies provide valuable information about the nature of cardiac involvement in patients with COVID-19. However, their small sample sizes make deriving a clear picture of the true frequencies of cardiovascular complications in this novel disease challenging. In this international collaboration, we undertook a systematic review to better understand the pathologic cardiac findings in patients with COVID-19 at the time of postmortem evaluation.

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Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The protocol of this review was registered in PROSPERO (CRD42020223551).

Literature search and study selection

The literature was searched by a medical librarian for the concepts of autopsy or histopathology combined with COVID-19. The search strategies were created using keywords and standardized index terms (Doc. S1). Searches were run in February 2021 in Ovid EBM Reviews, Ovid Embase (1974+), Ovid Medline (1946+, including ePUB ahead of print, in-process, and other nonindexed citations), Scopus (1970+), and Web of Science (1975+). We also searched for unpublished manuscripts using the medRxiv services operated by Cold Spring Harbor Laboratory. In addition, we searched Google Scholar and the references of eligible studies and review articles.

Articles were considered eligible for inclusion if they were studies with human participants and reported cardiac autopsy findings among individuals with a SARS-CoV-2 infection. We included studies published in any language.

Identification of studies

Two reviewers (RA and SO) examined the titles and abstracts of articles using the studies selection criteria. Then, they examined the full texts to confirm that each article met the eligibility criteria.

Data collection

Data were extracted by two reviewers (R.A. and S.O.) and in duplicates into a prespecified data collection form. Disagreements were discussed with the senior reviewers (I.T. and T.K.). Data were collected on the following prespecified outcomes: 1) Study location, study type, number of cases, patient selection, selection bias, and autopsy type; 2) baseline characteristics, including age, sex, ethnicity, body mass index, cause of death, days to death, and presence of comorbidities; 3) laboratory test values, including maximum serum troponin levels, serum brain natriuretic peptide, serum ferritin, and D-dimer levels; 4) cardiac autopsy findings; and 5) ultrastructural studies, including immunohistochemistry and electron microscopy. The Cardiac Autopsy in COVID-19 Study Group collaborators completed a data collection form (Doc. S2).

One author assessed the studies for risk of selection, detection, and reporting biases. Specifically, studies were evaluated on whether consecutively deceased patients with COVID-19 underwent a cardiac autopsy to reduce selection bias.

Statistical analyses

The number and percentage of patients manifesting different findings during cardiac autopsies were extracted from each study and confirmed with the studies’ authors. We initially planned to perform meta-analyses to obtain pooled estimates of the different findings’ prevalences. However, this was not possible due to the limited number of studies that performed consecutive cardiac autopsies. We report the median prevalence of cardiac autopsy findings across studies with sample sizes ≥5, with associated interquartile ranges (IQRs) (see Table 1 ).

Table 1

Summary of median prevalence of cardiac autopsy findings of studies with ≥5 patients

Autopsy findingPathology classificationNumber of studiesTotal number of patientsMedian, %Quarter 1, %Quarter 3, %
Viral presenceVirology1011660.840.495.6
Extensive myocarditisMyocarditis101750.00.00.0
Focal active myocarditisMyocarditis132350.00.013.4
Multifocal myocarditisMyocarditis91310.00.02.1
Infiltrates without myocyte injuryMyocarditis152790.60.09.8
Pulmonary embolismThromboembolic1531122.216.732.1
Microvessel thrombiThromboembolic810336.217.661.7
Cardiac large vessel thrombiThromboembolic916214.313.322.8
Acute myocardial infarctionThromboembolic710411.87.913.8
Small vessel vasculitisInflammatory38628.616.032.5
Epi-pericarditisInflammatory611015.511.919.2
Cardiac oedemaGross pathology44655.519.592.5
NecrosisGross pathology964100.020.0100.0
FibrosisChronic1318342.935.090.5
AmyloidosisChronic813113.69.817.4
Atherosclerotic coronary artery diseaseChronic1425046.221.680.1
HypertrophyChronic1830369.046.892.1

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Results

Search results and studies characteristics

The search yielded 4760 results. We examined the entire text of 58 manuscripts after removing duplicates and screening the titles. However, eight studies were excluded, leaving 50 studies with 548 hearts in the final cohort (Fig. 1 ). Most studies were case reports (n = 13) or case series (n = 37; Doc. S3). Autopsy cases were acquired from manuscripts spanning experiences from 15 countries. The number of cases per study ranged from 1 to 80 (median: 4.5), and five cases were identified as reporting consecutive autopsies (encompassing 155 subjects) [[18], [19], [20], [21], [22]]. There were 42 minimally invasive autopsies, 102 partial autopsies, and 301 complete autopsies among the autopsies where completeness was stated or could be inferred.

Fig. 1

Fig. 1

Preferred Reporting Items for Systematic Reviews and Meta-analyses 2009 flow diagram.

Patient demographics, comorbidities, and cause of death

The median age of the deceased was 69 years (range, 22–97 years; n = 548), and 62% of cases were men (n = 338 of 548). The most common comorbidities were systemic hypertension (n = 298; 56%) and coronary artery disease (n = 252; 49%). Other less common comorbidities included chronic obstructive pulmonary disease, diabetes, obesity, chronic kidney disease, old myocardial infarction, dementia, malignancy, and sleep apnoea (Fig. 2 ). Elevated troponin was demonstrated in 55% of cases.

Fig. 2

Fig. 2

Bar chart showing reported comorbidities of deceased patients included in this cohort. CAD, coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; MI, myocardial infarction. Data labels show the prevalence of reported comorbidities (can overlap in a single patient).

The cause of death was reported in 479 cases, with the most reported being respiratory in origin. However, in 62 cases, cardiac involvement was identified as a key factor in mortality. The median time from the onset of symptoms to death was 9 days (range, 0–71 days; n = 401).

Cardiovascular autopsy findings

General findings

Cardiac abnormalities were found in gross pathology or histology test results in almost all cases. Heart weights were available for 276 hearts (51%), with a median weight of 465 g (range, 238–1070 g).

SARS coronavirus type to infection of the heart

Nineteen studies [[17], [18], [19], [23], [24], [25], [26], [27], [28]] with 217 cases explored the presence and localization of SARS-CoV-2 infection in the heart using different modalities, including RT-PCR, immunohistochemistry, in situ hybridization, and electron microscopy. Ten studies [18,19,[26], [27], [28],30,32,33,35,37] with a total of 116 cases detected SARS-CoV-2 infection in the cardiac tissues in 70 cases with a median of 60.8% (IQR, 40.4%–95.6%; Fig. 3 ).

Fig. 3

Fig. 3

Box-and-whisker plot of cardiac autopsy findings of studies with ≥5 patients as median percentage prevalence and associated interquartile ranges. CAD, coronary artery disease.

Active replication of SARS-CoV-2 within the heart was determined using the RNA scope in situ hybridization technique looking for the presence of the negative strand of the SARS-CoV-2 viral RNA or through the identification of subgenomic RNA, both of which indicate active viral replication. Four investigators employed these techniques in 55 cases [18,27,28,33], and verified the presence of active SARS-CoV-2 viral replication in 15 hearts (27%).

Localization of SARS-CoV-2 within different cardiac cell compartments was studied by nine investigators [23,25,26,30,33,34,[36], [37], [38]] in 56 hearts from total of 95 cases using electron microscopy or immunohistochemistry. The presence of SARS-CoV-2 infection within the cardiomyocytes was reported in 11 hearts by four investigators [30,33,34,36]. SARS-CoV-2 infection was also detected in cardiac vascular endothelial cells in seven hearts and in cardiac fibroblasts in one heart [26,34]. On the other hand, other investigators [23,25,26,37,38] could not detect SARS-CoV-2 infection within any cell type in the heart.

Myocarditis

The majority of studies did not specify what definition of myocarditis was used. However, we inferred from the description of the histopathological findings that the Dallas criteria were used by most studies. Several investigators used immunohistochemical studies with different antibodies to identify subtypes of cellular infiltrates, but most did not use immunohistochemical criteria to diagnose myocarditis. In total, 36 cases had myocarditis and 16 had inflammatory infiltrates but no myocyte damage (Fig. 3).

Few cases reported extensive myocarditis, ranging from 0.0% to 19.3%, with a median of 0.0% across 10 studies [20,23,26,28,32,37,[39], [40], [41], [42]] with a total of 175 cases (Fig. 3). Grosse et al., who authored the only consecutive study to report a prevalence for this finding, did not find any cases of extensive myocarditis across 14 cases. Focal active myocarditis was reported by 13 studies [20,21,23,25,26,28,32,[37], [38], [39], [40],42,43], ranging from 0.0% to 55.5%. Nine studies [19,20,26,28,32,37,39,42,44] with total of 131 cases described multifocal myocarditis with a median prevalence of 0.0% (IQR, 0.0%–2.1%). Finally, 15 studies [18,[20], [21], [22],[26], [27], [28],32,35,37,39,40,42,44,45] with 279 cases reported infiltrates without myocyte damage with a median prevalence of 0.6% (range, 0.0%–28.9%; Fig. 3).

Other acute cardiac pathologic changes

Necrosis had the highest median reported prevalence across nine studies, of which none were considered consecutive studies, including 64 autopsies [28,29,31,34,40,43,[46], [47], [48]] with a median of 100% (n = 64; IQR, 20.0%–100%). This was followed by cardiac interstitial oedema (n = 46; median: 55%; IQR, 19.5%–92.5%) [22,27,30,42], with Duarte-Neto et al. reporting a prevalence of 90% across ten consecutive autopsies (Fig. 3).

Microvessel thrombi had the highest reported median prevalence across the category of thromboembolic disease among eight studies, reporting a similar prevalence across the studies [22,23,27,28,30,38,44,49] with 43 of 103 cases (median: 36.2%; IQR, 17.5%–61.7%). Alternatively, acute myocardial infarction had the lowest reported median prevalence in this category (median: 11.8%; IQR, 7.9%–13.8%; Fig. 3). Acute epi-pericarditis was reported with a median prevalence of 15.5% (IQR, 11.9%–19.2%) across six studies [28,30,33,38,39,41] in 29 of 110 cases, and small vessel vasculitis had a median reported prevalence of 28.6% (IQR, 16.0%–32.5%) across three studies [38,41,43] in 12 of 86 cases (Fig. 3). Other less frequently reported findings include single-cell ischemia in one of seven patients [35], myocyte ischemic degeneration with pyknosis in one case report [50], and contraction bands in one of three cases [51].

Chronic cardiac findings

Hypertrophy was the most common pathological finding with a median of 69.0% (IQR, 46.8%–92.1%) across 18 studies [[18], [19], [20],22,23,25,28,[31], [32], [33],35,38,39,[41], [42], [43],45,49] in 197 of 303 cases. Fibrosis was reported in 13 studies [20,22,25,27,28,[30], [31], [32],37,[42], [43], [44], [45]] with a median of 42.9% (IQR, 35.0%–90.5%) in 104 of 183 cases. Among these 13 studies, ten studies reported various details about the nature of fibrotic changes [20,25,27,28,30,31,37,42,44,45]. Two studies [42,44] reported on the severity of fibrosis with 32 cases (20 with mild and 8 with moderate fibrosis). Six studies [20,27,28,30,31,44] reported on the extent of fibrosis in a total of 98 cases. There was fibrosis in 46 of these cases, which was diffuse in 18 cases and focal or patchy in 28 cases. Replacement fibrosis was described by two authors [25,27] in eight cases. Eight studies [18,20,23,25,28,31,35,45,49] with 131 patients observed amyloidosis in 21 cases with a median prevalence of 13.6% (IQR, 9.8%–17.4%). The type of amyloidosis was reported in 14 of these cases, and determined to be transthyretin in 13 cases and amyloid P in one case, with patient age ranging between 71 and 96 years [20,23,28,31,35,45]. Other less-reported pathologies were chronic pericarditis, reported by three studies in 17 of 47 cases [28,33,43], and ischemic heart disease in 1 of 3 cases in one study [50].

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Discussion

General autopsy findings and clinical correlation

This systematic review of pathology-derived cardiac changes in patients with COVID-19 included 50 studies with more than 500 cases, and was the effort of an international collaboration. The most prevalent chronic changes were myocardial hypertrophy, underlying coronary artery disease, and fibrosis (median: 69.0%, 46.2%, and 42.9%, respectively). The high prevalence of chronic cardiac pathologies among patients who died due to COVID-19 supports the findings from previously published epidemiologic studies [[1], [2], [3]].

Interestingly, another underlying cardiac disease, amyloidosis, was reported in a median of 13.6% of patients with COVID-19, with patient age ranging between 71 and 96 years. The overall prevalence of cardiac amyloidosis in an unselected, sequential autopsy population was reported at approximately 4% [23]. Conversely, a Finnish autopsy study of individuals age >85 years detected cardiac amyloidosis in 25% of cases [52]. Although cardiac amyloidosis prevalence almost certainly increases with patient age, cardiac amyloidosis is also likely underdiagnosed, particularly among patients with heart failure and preserved ejection fraction [[53], [54], [55]]. Nevertheless, the relatively high proportion of cardiac amyloidosis among decedents with COVID-19 compared with unselected autopsy rates suggests that this condition may render patients vulnerable to adverse outcomes from SARS-CoV-2 infection. This is further supported by the average age of patients with cardiac amyloidosis who died of COVID-19. Possible mechanisms for this complication have been proposed; however, decreased cardiac reserve innate to underlying cardiovascular disease, including amyloidosis, likely plays a significant role [56].

The prevalence of acute thromboembolic pathologies in descending frequency included microvessel thrombi (36.2%), pulmonary embolism (22.2%), cardiac large vessel thrombosis (14.3%), and acute myocardial infarction (11.8%). The increased cardiac and pulmonary vascular thrombi correlate strongly with the clinical evidence of increased thromboembolic phenomena in patients with COVID-19. Moreover, these thrombotic changes, along with the observed high prevalence of acute cardiac injuries (e.g. necrosis, oedema, and epi-pericarditis) are concordant with the clinically documented ventricular dysfunction [6] and serologic markers of cardiac injury, such as increased troponins [[7], [8], [9], [10]]. In fact, microvascular thrombosis has been cited as the causative agent of cardiac injury in most decedents with COVID-19 [57]. This finding dovetails with the lower prevalence of large vessel cardiac thrombosis, and is consistent with the coronary angiographic findings in patients with COVID-19, wherein a culprit lesion was not identified in more than 40% of patients with suspected acute myocardial infarction [14].

SARS-CoV-2 cardiac tropism

SARS-CoV-2 gains entry into the host cells through the binding of its spike protein to the angiotensin-converting enzyme 2 with the help of the host transmembrane protease serine 2 [58]. Both proteins have been shown to be expressed in the heart [23,[59], [60], [61]]. The predecessor of SARS-CoV-2 (SARS-CoV and its associated syndrome SARS) also uses the angiotensin-converting enzyme 2 protein for cell entry, and has been shown to infect the heart and induce inflammatory changes based on data from the first decade of the 21st century [61]. These findings, along with the clinical observations of acute cardiac injury among patients with COVID-19, prompted several investigators to address three important questions: 1) Is SARS-CoV-2 present in the hearts of decedents with COVID-19; 2) if so, which cell type(s) does SARS-CoV-2 infect; and 3) can SARS-CoV-2 replicate in heart tissues?

Twenty studies explored the presence of SARS-CoV-2 within the heart, the majority of which targeted the identification of SARS-CoV-2 RNA in heart tissues using RT-PCR or in situ hybridization. Other employed techniques included immunohistochemistry to identify SARS-CoV-2 proteins (e.g. spike or nucleocapsid protein), as well as electron microscopy. These investigators identified the presence of SARS-CoV-2 in almost 60% of the examined hearts. Additionally, a few investigators identified SARS-CoV-2 replication within heart tissues in several cases [18,27,28,33]. Furthermore, studies investigated cell-type localization of SARS-CoV-2 within the heart, and provided evidence of the presence of SARS-CoV-2 viral particles within the cardiomyocytes [30,33,34,36]. Bulfamante et al. observed degenerative changes in cardiomyocytes containing SARS-CoV-2 viral particles [33]. These findings are supported by a study that demonstrated SARS-CoV-2 infection and propagation in induced pluripotent stem cell-derived cardiomyocytes [62]. SARS-CoV-2 has also been found in vascular endothelial cells and cardiac fibroblasts [26,34]. These reports establish SARS-CoV-2 cardiac tropism, and present a possible link between SARS-CoV-2 and certain acute cardiac pathologies (e.g. myocarditis). However, although RT-PCR represents a time-efficient method to determine tissue positive for SARS-CoV-2, RT-PCR does not allow for tissue localization. Wong et al. suggested and attempted to validate a Fluorescence In Situ Hybridization (FISH) method using positive and negative controls by detecting endogenous human genes (POLR2A and PPIB) and a bacterial gene (dap gene of Bacillus subtilis) to allow for a tissue-specific analysis [63].

SARS-CoV-2-induced myocarditis

In this review, we subdivided the reported cardiac inflammatory processes in patients with COVID-19 into four categories based on the degree of myocardial involvement and the presence of associated myocyte damage. Overall, the prevalence of each category was low, with vast differences between individual studies that cannot be explained solely by the methodological differences of the studies, and likely indicate significant selection and reporting bias. The median reported prevalence of extensive myocarditis, multifocal active myocarditis, and focal active myocarditis were all 0.0%, and the median prevalence of inflammatory infiltrate without myocyte damage was 0.6%.

Regrettably, clinical correlation or pooled prevalence estimates in the included reported autopsy series were not possible due to the heterogenous results and paucity of clinical and imaging data provided. Nonetheless, reports of clinically diagnosed myocarditis with pathologic correlation have been reported among inpatients with COVID-19 [36,48,64]. Intriguingly, Gauchotte et al. demonstrated pathologic evidence of myocarditis without lung involvement, and further showed the presence of the SARS-CoV-2 genome in cardiomyocytes in this case [36]. This finding is concordant with other studies suggesting a greater degree of inflammation with viral presence in the heart [65].

The diagnosis of most cases of myocarditis included in this review were based on the Dallas criteria. This methodology, although widely accepted, is not without its inherent limitations. First and foremost, the Dallas criteria were developed to diagnose myocarditis by endomyocardial biopsy (EMB), not autopsy, wherein a more abundant amount of tissue is available for histologic evaluation. The generalization (and clinical significance) of small foci of myocyte damage within autopsy-derived cardiac tissue is challenging to ascertain. Other limitations of the Dallas criteria include significant interobserver variability and sampling errors [66,67].

Although less of an issue in autopsy-derived tissue, the focal nature of the disease leads to sampling errors that have been shown to compromise the sensitivity of the histopathological diagnosis of myocarditis by EMB [68,69]. Chow et al. had estimated that a mean of 17 samples per patient would be required to establish a diagnosis of myocarditis [69], which likely explains why examining an increased number of cardiac tissue blocks at the time of autopsy resulted in a greater likelihood of identifying focal myocarditis.

The overall low prevalence of myocarditis in patients with COVID-19 is of interest, particularly when placed in the greater context of the available literature. In a recent meta-analysis on the diagnosis of myocarditis by EMB (including 61 studies with 10,491 patients), the prevalence of myocarditis according to the Dallas criteria was 8.04% [70]. This diagnosis was made on the relatively limited amount of tissue provided by EMB. In contrast, this review shows a myocarditis prevalence of 8% in abundant available tissue, often comprising multiple blocks of myocardium with greater orders of magnitude in the amount of tissue to examine. The pretest factors among these data points differ, but underscores the overall low prevalence of myocarditis in COVID-19 deaths and is concordant with previous literature reviews on the topic [71].

Prior studies have shown the added sensitivity of immunohistochemistry in the diagnosis of myocarditis. Katzmann et al. showed that the sensitivity of the Dallas criteria in detecting myocarditis was much lower than when immunohistochemistry is utilized, with a detection rate of 50.8% (vs. 8.04% without immunohistochemistry) [70]. In another study of 84 cases of myocarditis based on the immunohistochemistry criteria, applying the Dallas criteria without immunohistochemistry would have categorized only 8% of these case as active myocarditis [72].

The true prevalence of myocarditis in COVID-19 remains very hard to determine from the current autopsy and imaging studies, the latter of which shows a discordantly high prevalence of myocarditis compared with postmortem examinations. A recent systematic review of cardiovascular magnetic resonance findings in COVID-19 including 199 patients showed that myocarditis was the most prevalent diagnosis (40.2%) [73]. Future studies should integrate clinical imaging and more rigorous and systematic autopsy studies to help resolve this issue. Such initiative should be conducted in the form of an international registry that uses a unified autopsy examination and imaging protocols in accordance with published guidelines [74,75].

Limitations

This systematic review included the largest number of studies and cases published to date on cardiac changes in fatal COVID-19 with both qualitative and quantitative analyses of different cardiac pathologies observed in COVID-19. However, our study has several limitations. First, the majority of the included studies were small. Second, these studies were heterogeneous in their methodologies and patient cultural origins, with very few studies performing consecutive autopsies, which makes meta-analyses unfeasible. Moreover, selection and reporting bias likely affected most included studies, as evidenced by the nonconsecutive nature of case recruitment and the very high differences between the studies in the perveances of reported pathologies.

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Conclusions

Our systematic review confirmed the high prevalence of acute and chronic cardiac pathologies in the autopsy-derived hearts of decedents with COVID-19. These findings help explain observations from clinical epidemiologic studies, such as thromboembolic phenomena and acute myocardial injury. Our study also provides evidence for SARS-CoV-2 cardiac tropism, and confirmed the low prevalence of myocarditis in patients with COVID-19.

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Author contributions

IMT designed the study. IMT, RA, SO, and MCB coordinated the study. DG designed and ran the literature search. RA, SO, OAO, RT, ZC, BZS, EB, and TK acquired the data, screened records, and extracted the data. IMT and OAO conducted the formal analyses. TK wrote the report with input from MCB and JJM. All authors provided critical conceptual input, analyzed and interpreted data, and critically revised the report.

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Transparency declaration

Elie Berbari reports royalties or licenses from UTD of <$5000 per year. Amy V. Rapkiewicz reports payment for expert testimony by Eric Hack, Esq. Bruno Märkl reports grants or contracts from the German Registry of COVID-19 Autopsies, funded by the Federal Ministry of Health and the Federal Ministry of Education and Research within the framework of the network of university medicine. Diana Lindner reports support for the present manuscript, grants, and contracts from the German Centre for Cardiovascular Research, Deutsche Herzstiftung. Dirk Westermann reports consulting fees and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Abiomed, Bayer, AstraZeneca, Novartis, and Medtronic. Klaus Hirschbühl reports grants or contracts from the German Registry of COVID-19 Autopsies, funded by the Federal Ministry of Health and the Federal Ministry of Education and Research within the framework of the network of university medicine. Luiz Fernando Ferraz da Silva reports grants or contracts, paid to their institution, from the Bill and Melinda Gates Foundation. Martin Lammens reports support for the present manuscript from the Belgian Fund for Scientific Research–Flanders. Michael Osborn reports grants or contracts from the North West London pathology research grant (£10,000), paid by their own institution, to set up a tissue bank and fund the procurement and use of tissue included in the current research, as well as payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Yale University ($300 for talking about COVID). He also reports a leadership or fiduciary role on a board, society, committee, or advocacy group as president of the Royal College of Pathologists, secretary of the BDIAP, president AAPT (all unpaid). Paulo Hilario Nascimento Saldiva reports support for the present manuscript from the Bill and Melinda Gates Foundation, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Fundação de Amparo à Pesquisa do Estado de São Paulo, and Hospital das Clinicas da Faculdade de Medicina da Universidade de Paulo–HC Convida. Tadaka Suzuki reports grants or contracts from the Japan Agency for Medical Research and Development and Japan Society for the Promotion of Science (grants in aid). There was no funding source for this study.

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Acknowledgments

The Cardiac Autopsy in COVID-19 Study Group consists of Alberto E. Paniz Mondolfi (Department of Pathology, Molecular and Cell-Based Medicine, New York, New York), Aloke V. Finn (CVPath Institute, Inc., Gaithersburg, Maryland; and University of Maryland, Baltimore, Maryland), Amaro Nunes Duarte-Neto (Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil), Amy V. Rapkiewicz (NYU Winthrop Hospital, Department of Pathology, Long Island School of Medicine, Long Island, New York), Andrea Frustaci (Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, La Sapienza University, Rome, Italy; and Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy), Arthur-Atilla Keresztesi (Fogolyan Kristof Emergency County Hospital, Covasna County Institution of Forensic Medicine, Covasna, Romania), Brian Hanley (Department of Cellular Pathology, Northwest London Pathology, Imperial College London NHS Trust, London, UK; and Centre for Inflammatory Disease, Imperial College London, London, UK), Bruno Märkl (Institute of Pathology and Molecular Diagnostics, University Medical Center Augsburg, Augsburg, Germany), Christelle Lardi (University Center of Legal Medicine, Geneva University Hospital, Geneva, Switzerland), Clare Bryce (Icahn School of Medicine at Mount Sinai, New York, New York), Diana Lindner (Department of Cardiology, University Heart and Vascular Centre, Hamburg, Germany; and DZHK–German Center for Cardiovascular Research, Partner site, Hamburg/Kiel/Lübeck, Germany), Diego Aguiar (University Center of Legal Medicine, Geneva University Hospital, Geneva, Switzerland), Dirk Westermann (Department of Cardiology, University Heart and Vascular Centre, Hamburg, Germany; and DZHK–German Center for Cardiovascular Research, Partner site, Hamburg/Kiel/Lübeck, Germany), Edana Stroberg (Office of the Chief Medical Examiner, Oklahoma City, Oklahoma), Eric J. Duval (Office of the Chief Medical Examiner, Oklahoma City, Oklahoma), Esther Youd (Forensic Medicine and Science, University of Glasgow, Glasgow, UK), Gaetano Pietro Bulfamante (Unità di Anatomia Patologica, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy; and Struttura Complessa di Anatomia Patologica e Genetica Medica, ASST Santi Paolo e Carlo, Milan, Italy), Isabelle Salmon (Department of Pathology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium; Centre Universitaire inter Régional d’expertise en Anatomie Pathologique Hospitalière, Jumet, Belgium; and DIAPath, Center for Microscopy and Molecular Imaging, ULB, Gosselies, Belgium), Johann Auer (Department of Cardiology and Intensive Care, St. Josef Hospital Braunau, Austria; and Department of Cardiology and Intensive Care, Kepler University of Medicine Linz, Austria), Joseph J. Maleszewski (Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota; and Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota), Klaus Hirschbühl (Department of Hematology and Clinical Oncology, University Medical Center Augsburg, Augsburg, Germany), Lara Absil (Department of Pathology, Erasme Hospital, ULB, Brussels, Belgium), Lisa M. Barton (Office of the Chief Medical Examiner, Oklahoma City, Oklahoma), Luiz Fernando Ferraz da Silva (Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; and Serviço de Verificação de Óbitos da Capital, Universidade de São Paulo, São Paulo, Brazil), Luiza Moore (Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; and Cancer, Ageing and Somatic Mutation, Wellcome Sanger Institute, Cambridge, UK), Marisa Dolhnikoff (Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil), Martin Lammens (Department of Pathology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium), Melanie C. Bois (Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota), Michael Osborn (Department of Cellular Pathology, Northwest London Pathology, Imperial College London NHS Trust, London, UK; Death Investigation Committee, Royal College of Pathologists, London, UK; and Nightingale NHS Hospital, London, UK), Myriam Remmelink (Department of Pathology, Erasme Hospital, ULB, Brussels, Belgium), Paulo Hilario Nascimento Saldiva (Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil), Philippe G. Jorens (Infla-Med Research Consortium of Excellence, University of Antwerp, Antwerp, Belgium; Department of Medicine and Health Sciences, Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium; and Department of Intensive Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium), Randall Craver (Children’s Hospital of New Orleans, New Orleans, Louisiana; and Louisiana State University Health Sciences Center, New Orleans, Louisiana), Renata Aparecida de Almeida Monteiro (Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil), Roberto Scendoni (Institute of Legal Medicine, Department of Law, University of Macerata, Macerata, Italy), Sanjay Mukhopadhyay (Department of Pathology, Cleveland Clinic, Cleveland, Ohio), Tadaki Suzuki (National Institute of Infectious Diseases, Tokyo, Japan), Thais Mauad (Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil), Tony Fracasso (University Center of Legal Medicine, Geneva University Hospital, Geneva, Switzerland), and Zachary Grimes (Icahn School of Medicine at Mount Sinai, New York, New York).

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Notes

Editor: L. Leibovici

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Footnotes

Appendix ASupplementary data to this article can be found online at https://doi.org/10.1016/j.cmi.2022.03.021.

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Appendix A. Supplementary data

The following are the Supplementary data to this article:

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Testimony of Dr Meryl Nass, MD before the Health and Human Services Committee Of the Maine Gov Legislature

March 3, 2023

Testimony of Meryl Nass, MD before the Health and Human Services Committee
January 11, 2022
Honorable Chairpersons, Members and Senators,
I write in support of LD 867. There are many reasons why preventing COVID vaccine mandates
until adequate, sufficient safety studies have been performed is the right decision for this
committee and legislature.
1. COVID vaccines are experimental
Let me say, first, that no matter what claims have been made regarding these vaccines, they are
not “safe and effective.” “Safe and effective” is an FDA ‘term of art’1 that may only be applied to
licensed drugs and vaccines. All currently available COVID vaccines in the United States are
unlicensed and experimental, a.k.a. investigational.
Medicines and vaccines are either licensed products or experimental products. There is no gray
area between them in US law. Whether or not research is explicitly conducted, the use of
experimental products (including those issued under an Emergency Use Authorization) falls
under the Nuremberg Code and under US law regulating experimental drugs. As former FDA
Commissioner Stephen Hahn himself noted, “EUA products are still considered
investigational.”

2According to 21CFR Subchapter D Part 312:3 “an experiment is any use of a drug except for the
use of a marketed drug in the course of medical practice.” Vaccines are considered a subset of
drugs by FDA.4 And the use of unlicensed, Emergency Use Authorized vaccines is thus, by
definition, experimental.
US law requires that humans receiving experimental products must provide written informed
consent.
5 However, when the PREP Act creating Emergency Use Authorizations (EUAs) was
written, this requirement was loosened slightly for emergencies in which EUA products would
be used. The required disclosures when using EUAs were specified below. Please note the
option to accept or refuse.

21 U.S. Code § 360bbb–3 – Authorization for medical products for use in emergencies6
(ii) Appropriate conditions designed to ensure that individuals to whom the product is
administered are informed—
1 https://www.fda.gov/science-research/risk-communication/fdas-risk-communication-research-agenda
2 https://www.usatoday.com/story/news/2020/11/24/fda-commissioner-stephen-hahn-timing-safety-covid-19-
vaccine/6393865002/
3https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=312.3#:~:text=Clinical%20investigation
%20means%20any%20experiment,the%20course%20of%20medical%20practice.
4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152379/
5 https://www.ecfr.gov/on/2018-07-19/title-45/subtitle-A/subchapter-A/part-46#sp45.1.46.a
6 https://www.law.cornell.edu/uscode/text/21/360bbb-32
(I) that the Secretary has authorized the emergency use of the product;
(II) of the significant known and potential benefits and risks of such use, and of the
extent to which such benefits and risks are unknown; and
(III) of the option to accept or refuse administration of the product, of the consequences,
if any, of refusing administration of the product, and of the alternatives to
the product that are available and of their benefits and risks.
All Moderna, Janssen (Johnson and Johnson) and all childhood Pfizer-BioNTech vaccines are
being used under EUAs. And while the adult Pfizer-BioNTech vaccine is supposed to be
licensed with brand name Comirnaty, in fact the Pfizer vaccines being used in the US today are
EUA products as well.
2. While FDA licensed Comirnaty, the only approved COVID vaccine, only Emergency
Use Authorized (experimental) vaccines are being used

Despite claims to the contrary, the only vaccine currently available in the US is the Pfizer-
BioNTech, not the licensed and branded Comirnaty. The Pfizer-BioNTech vaccine is authorized
under an Emergency Use Authorization, which provides a broad liability shield to the
manufacturer, distributor, administrator, program planner, and virtually anyone else involved in
the vaccination process. The branded product, on the other hand, is subject to ordinary liability
claims at the present time.
Exactly three weeks after FDA issued Comirnaty a license, the National Library of Medicine,
part of the NIH, posted information that Pfizer was not planning to make Comirnaty available in
the US while the EUA vaccine was still available:7
“SEPTEMBER 13, 2021
Pfizer received FDA BLA license for its COVID-19 vaccine
Pfizer received FDA BLA license on 8/23/2021 for its COVID-19 vaccine for use in
individuals 16 and older (COMIRNATY). At that time, the FDA published a BLA package
insert that included the approved new COVID-19 vaccine tradename COMIRNATY and
listed 2 new NDCs (0069-1000-03, 0069-1000-02) and images of labels with the new
tradename.
At present, Pfizer does not plan to produce any product with these new NDCs and
labels over the next few months while EUA authorized product is still available and
being made available for U.S. distribution. As such, the CDC, AMA, and drug
compendia may not publish these new codes until Pfizer has determined when the
product will be produced with the BLA labels.”
FDA extended the vaccine’s EUA authorization on the same day it licensed the vaccine.
7 https://dailymed.nlm.nih.gov/dailymed/dailymed-announcements-details.cfm?date=2021-09-133
FDA appears to have been acceding to the White House demand that the vaccine be licensed, in
order for it to be mandated for large sectors of the US population. Under an EUA, which
specifies that potential recipients have the right to refuse,8 mandates cannot be imposed. So a
license was issued, allowing the administration to inform the public that the vaccine was fully
approved and licensed. But in fact, the public was unable to access the licensed vaccine.
Why was this convoluted regulatory process performed? While under EUA, Pfizer has an almost
bulletproof liability shield. According to the Congressional Research Service (CRS) on
September 23, 2021,9 “courts have characterized PREP Act immunity as ‘sweeping.'” The CRS
explains, “the PREP Act immunizes a covered person from legal liability for all claims for loss
relation to the administration or use of a covered countermeasure.”
3. FDA instructed Pfizer-BioNTech that FDA’s Congressionally-mandated databases are
inadequate to assess the danger of myocarditis (and other potential COVID vaccine side
effects) and therefore Pfizer-BioNTech must perform studies to evaluate these risks over
the next six years
On the day FDA issued a license for Comirnaty, August 23, 2021, FDA instructed Pfizer-
BioNTech that it did NOT have sufficient information on serious potential risks of the product,
and required Pfizer and BioNTech, the manufacturers, to conduct a series of studies to assess
these potential risks.
10 These studies were to be performed on both products: the licensed
Comirnaty and the EUA Pfizer-BioNTech vaccine. Note that they include the requirement for a
safety study in pregnancy, which will not be completed until December 31, 2025.
I have reproduced part of what FDA wrote about these required safety studies below, directly
from pages 6-11 of the FDA approval letter sent to BioNTech, linked below.
FDA’s admission that it cannot assess these safety risks, and that up to 6 years will be taken to
study them, provides us with additional de facto evidence that the Pfizer vaccines cannot be
termed safe, as many of the fundamental safety studies are only now getting started.
https://www.fda.gov/media/151710/download
“POSTMARKETING REQUIREMENTS UNDER SECTION 505(o) Section 505(o) of
the Federal Food, Drug, and Cosmetic Act (FDCA) authorizes FDA to require holders of
approved drug and biological product applications to conduct postmarketing studies and
clinical trials for certain purposes, if FDA makes certain findings required by the statute
(section 505(o)(3)(A), 21 U.S.C. 355(o)(3)(A)).
We have determined that an analysis of spontaneous postmarketing adverse events
reported under section 505(k)(1) of the FDCA will not be sufficient to assess known
8 https://www.law.cornell.edu/uscode/text/21/360bbb-3
9 https://crsreports.congress.gov/product/pdf/LSB/LSB10443
10 https://www.fda.gov/media/151710/download4
serious risks of myocarditis and pericarditis and identify an unexpected serious risk
of subclinical myocarditis.
Furthermore, the pharmacovigilance system that FDA is required to maintain under
section 505(k)(3) of the FDCA is not sufficient to assess these serious risks.
Therefore, based on appropriate scientific data, we have determined that you are
required to conduct the following studies:
4. Study C4591009, entitled “A Non-Interventional Post-Approval Safety Study of the
Pfizer-BioNTech COVID-19 mRNA Vaccine in the United States,” to evaluate the
occurrence of myocarditis and pericarditis following administration of COMIRNATY.

We acknowledge the timetable you submitted on August 21, 2021, which states that you
will conduct this study according to the following schedule: Final Protocol Submission:
August 31, 2021 Monitoring Report Submission: October 31, 2022 Interim Report
Submission: October 31, 2023 Study Completion: June 30, 2025 Final Report
Submission: October 31, 2025
5. Study C4591021, entitled “Post Conditional Approval [EUA] Active Surveillance
Study Among Individuals in Europe Receiving the Pfizer-BioNTech Coronavirus
Page 7 – STN BL 125742/0 – Elisa Harkins Disease 2019 (COVID-19) Vaccine,” to
evaluate the occurrence of myocarditis and pericarditis following administration of
COMIRNATY.
We acknowledge the timetable you submitted on August 21, 2021, which
states that you will conduct this study according to the following schedule: Final Protocol
Submission: August 11, 2021 Progress Report Submission: September 30, 2021 Interim
Report 1 Submission: March 31, 2022 Interim Report 2 Submission: September 30, 2022
Interim Report 3 Submission: March 31, 2023 Interim Report 4 Submission: September
30, 2023 Interim Report 5 Submission: March 31, 2024 Study Completion: March 31,
2024 Final Report Submission: September 30, 2024
6. Study C4591021 sub-study to describe the natural history of myocarditis and
pericarditis following administration of COMIRNATY.
We acknowledge the timetable
you submitted on August 21, 2021, which states that you will conduct this study
according to the following schedule: Final Protocol Submission: January 31, 2022 Study
Completion: March 31, 2024 Final Report Submission: September 30, 2024

7. Study C4591036, a prospective cohort study with at least 5 years of follow-up for potential
long-term sequelae of myocarditis after vaccination (in collaboration with Pediatric Heart
Network).
We acknowledge the timetable you submitted on August 21, 2021, which
states that you will conduct this study according to the following schedule: Final Protocol
Submission: November 30, 2021 Study Completion: December 31, 2026 Page 8 – STN
BL 125742/0 – Elisa Harkins Final Report Submission: May 31, 2027
8. Study C4591007 sub-study to prospectively assess the incidence of subclinical
myocarditis following administration of the second dose of COMIRNATY in a subset of
participants 5 through 15 years of age.
We acknowledge the timetable you submitted on
August 21, 2021, which states that you will conduct this assessment according to the5
following schedule: Final Protocol Submission: September 30, 2021 Study Completion:
November 30, 2023 Final Report Submission: May 31, 2024
9. Study C4591031 sub-study to prospectively assess the incidence of subclinical
myocarditis following administration of a third dose of COMIRNATY in a subset of
participants 16 to 30 years of age.
We acknowledge the timetable you submitted on
August 21, 2021, which states that you will conduct this study according to the following
schedule: Final Protocol Submission: November 30, 2021 Study Completion: June 30,
2022.
Final Report Submission: December 31, 2022 …
10. Study C4591022, entitled “Pfizer-BioNTech COVID-19 Vaccine [the EUA vaccine]
Exposure during Pregnancy:
A Non-Interventional Post-Approval Safety Study of
Pregnancy and Infant Outcomes in the Organization of Teratology Information
Specialists (OTIS)/MotherToBaby Pregnancy Registry.”
Final Protocol Submission: July 1, 2021 Study Completion: June 30, 2025
Final Report Submission: December 31, 2025
4. The World Health Organization does not recommend COVID vaccines for normal
children

The WHO website “WHO SHOULD GET VACCINATED”11 states the following:
Children and adolescents tend to have milder disease compared to adults, so unless they
are part of a group at higher risk of severe COVID-19, it is less urgent to vaccinate them
than older people, those with chronic health conditions and health workers.
More evidence is needed on the use of the different COVID-19 vaccines in children to be
able to make general recommendations on vaccinating children against COVID-19.
WHO’s Strategic Advisory Group of Experts (SAGE) has concluded that the
Pfizer/BionTech vaccine is suitable for use by people aged 12 years and above. Children
aged between 12 and 15 who are at high risk may be offered this vaccine alongside other
priority groups for vaccination. Vaccine trials for children are ongoing and WHO will
update its recommendations when the evidence or epidemiological situation warrants a
change in policy.
If the World Health Organization believes there is insufficient evidence to support general
vaccination of normal children, why would this committee and the Maine Legislature think
otherwise?
To sum up:
11 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/advice6
 All available COVID vaccines are experimental products
 They must legally provide recipients the right to refuse.
 Mandates negate the right of refusal.
 Basic safety questions regarding the vaccines have not been resolved, and some will not
be answered until 2027.
 The WHO does not recommend broad COVID vaccinations for children
 Parents should be permitted to make individualized decisions regarding their children’s
risks and benefits from COVID vaccines.
 Unfortunately, no one can make a fully informed decision about COVID vaccines until
the public has access to complete information on safety and efficacy, which are not now
available.

Thank you very much for your attention.
Meryl Nass, MD
210 Main St.
Ellsworth, Maine 04605
merylnass@gmail.com
610-5885 office
610-5886

Bill Gates Crimes 2023-03-02 Jorma A Jyrkkanen, BSc,PDP

March 2, 2023

Bill Gates Crimes Short List. 2023-03-02. Jorma Jyrkkanen, BSc, PDP

Jorma Jyrkkanen

BILL GATES CRIMES: U.S. patents show CDC ownership of Coronavirus. Both China and the U.S. involved in the creation of Wuhan SARS-CoV-2. Gates and CCP controlled WHO appoints criminal Tedros. CDC, FDA, CIA, NIH, Gates, Fauci, Baric, Rockefeller are all involved in Federal Crimes.

Bill Gates and the Rockefeller foundation paid Google, Facebook, Politico, Wikipedia, Fact Checkers in order to censor and control all the information.

GIRLS IN AFRICA VACCINATED FOR DTP HAD 10X THE MORTALITY OF THOSE NOT VACCINATED. GATES WANTED TO VACCINATE 160 MILLION W DTP (Whooping Cough, measles and mumps)

https://twitter.com/i/status/1701418737562464632

The CIA has been using Operation Mockingbird for years and has over 3,000 agents implanted in Mainstream Media to control the population.

Event 201 was sponsored by Bill Gates, the Johns Hopkins Center for Health Security (CIA) and the World Economic Forum to enforce a worldwide Pandemic response 5 months before the WHO fraudulently declared a global pandemic. It was a planned coordinated criminal effort worldwide.

In January 2017 Anthony Fauci said there will be a surprise virus outbreak before the end of 2020. Bill Gates in 2015 talked of a future pandemic and lied in April 2020 when he said they did not simulate or practice for a pandemic.

Klaus Schwab in his book Covid-19 The Great Reset shows Covid was the Trojan Horse to Reset the World according to the UN 2030 Agenda. Build Back Better slogan is a criminal coordinated effort to remove human rights and institute a one world government.

Bill Gates and the Rockefeller foundation bribes the WHO, NIH, NIAID, CDC, FDA, Medical Schools and Journals to control the health industry and public health policy.

WHO Chief Tedros involved in genocide killing and torture in Ethiopia. Tedros is a known member of the communist party. He is Beijing’s and Bill Gates puppet. As a Health Minister he was accused of covering up three Cholera Epidemics and committing crimes against humanity. The CCP and Bill Gates helped put Tedros in charge of the WHO.

John D. Rockefeller over 100 years ago seized the U.S. Media and took control over public health using toxic petroleum based drugs for profit and controlled the American Medical Association blacklisting and expelling any doctors who practiced natural medicine.

Rockefeller’s poison injections and medicines started causing cancer in early years and to cover it up formed the American Cancer Society. Medical error is the 3rd leading cause of death in America.

Bill Gates used India and Africa as guinea pigs for pharmaceutical companies to make a financial killing while killing a lot of people in the process including killing innocent children and babies with vaccines. Bill Gates controls GAVI The Vaccine Alliance to vaccinate the world with his poisons.

National Security Study Memorandum NSSM 200 Implications of Worldwide Population Growth For U.S. Security and Overseas Interests December 10, 1974 (THE KISSINGER REPORT) shows the intention of governments to reduce the population.

Bill Gates is one of the key funders in the Stratosphere experiment to block out the sun for Climate Change by releasing poisons in the air. Environmental Scientist call it global genocide experiment. Gates has invested over one billion dollars in the Earth Now Global Surveillance project to launch hundreds of satellites to monitor people everywhere 24/7 a day.

In partnership with MIT Bill Gates has developed a new technology that allows vaccines to be injected under your skin along with your medical records. Bill Gates Gates funded genetically modified mosquitoes released in the USA to allow human immunization by means of mosquito bites “Flying Syringes.”

Bill Gates had business dealings and a relationship with Jeffrey Epstein, a convicted child sex criminal. Why would he choose to partner with the world’s most notorious pedophile? To Blackmail?

His Troubles in India

https://www.youtube.com/watch?v=Mo881ysLt4Y

BILL GATES NAME APPEARS ON THE EPSTEIN ISLAND VISITOR LIST

Bill Gates is the top financial donor of the WHO and CDC. No one person has more power than Gates to influence and control the health and medical freedom of all people. Bill Gates and all mRNA Vaccines must be stopped. This is a global genocide experiment and a takeover of the world.

EVENT 2011 JOINT MOCK PANDEMIC OPERATION BY BILL AND MELINDA GATES, JOHNS HOPKINS AND WORLD ECONOMIC FORUM DURING WUHAN OLYMPIC GAMES HELD IN USA. https://www.centerforhealthsecurity.org/our-work/exercises/event201/

Bill Gates stating he would like to reduce the worlds population with his vaccines.

https://twitter.com/i/status/1701112870321393838