Six Questions about the Kids' COVID Vaccine, Answered by an Infectious Disease Doctor
I enthusiastically support the vaccination against COVID for children aged 5-11 years old. As an infectious disease doctor who took care of hundreds of COVID-19 patients over the past 20 months, I have seen the immediate and long-term consequences of COVID-19 on patients – and on their families. As a father of two daughters, I have lived through the fear and anxiety of protecting my kids at all cost from the scourges of the pandemic and worried constantly about bringing the virus home from work.
It is imperative that we vaccinate as many children in the community as possible. There are several reasons why. First children do get sick from COVID-19. Over the course of the pandemic in the U.S, more than 2 million children aged 5-11 have become infected, more than 8000 have been hospitalized, and more than 100 have died, making COVID one of the top 10 causes of pediatric deaths in this age group over the past year. Children are also susceptible to chronic consequences of COVID such as long COVID and multisystem inflammatory syndrome in children (MIS-C). Most studies demonstrate that 10-30% of children will develop chronic symptoms following COVID-19. These include complaints of brain fog, fatigue, trouble breathing, fever, headache, muscle and joint pains, abdominal pain, mood swings and even psychiatric disorders. Symptoms typically last from 4-8 weeks in children, with some reporting symptoms that persist for many months.
Second, children are increasingly recognized as vectors who can bring infection into the house, potentially transmitting infection to vulnerable household members. Finally, we have all seen the mayhem that results when one child in the classroom becomes infected with COVID and the other students get sent home to quarantine – across the U.S., more than 2000 schools have been affected this way.
We now have an extraordinarily effective vaccine with more than 90 percent efficacy at preventing symptomatic infection. Vaccinating children will boost our countrywide vaccination rate which is trailing many countries after an early start. Nevertheless, there are still many questions and concerns that parents have as the vaccine gets rolled out. I will address six of them here.
"Novel Vaccine Technology"
Even though this is a relatively new vaccine, the technology is not new. Scientists had worked on mRNA vaccines for decades prior to the COVID mRNA vaccine breakthrough. Furthermore, experience with the Pfizer COVID vaccine is rapidly growing. By now it has been more than a year and a half since the Pfizer trials began in March 2020, and more than 7 billion doses have already been administered globally, including in 13.7 million adolescents in the U.S. alone.
"Will This Vaccine Alter My Child's DNA?"
No. This is not how mRNA works. DNA is present in the cell's nucleus. The mRNA only stays in the outside cytoplasm, gets destroyed and never enters the inner sanctum of the nucleus. Furthermore, for the mRNA to be ever integrated into DNA, it requires a special enzyme called reverse transcriptase which humans don't have. Proteins (that look like the spike proteins on SARS-CoV-2) are made directly from this mRNA message without involvement of our DNA at any time. Pieces of spike proteins get displayed on the outside of our cells and our body makes protective antibodies that then protects us handily against the future real virus if it were ever to enter our (or our children's) bodies. Our children's DNA or genes can never be affected by an mRNA vaccine.
"Lack of Info on Long-Term Side Effects"
Unlike medications that are taken daily or periodically and can build up over time, the mRNA in the Pfizer vaccine is evanescent. It literally is just the messenger (that is what the "m" in mRNA stands for) and the messenger quickly disappears. mRNA is extremely fragile and easily inactivated – that's why we need to encase it in a special fatty bubble and store the vaccines at extremely cold temperatures. Our cells break down and destroy the mRNA within a few days after receiving the instructions to make the virus spike proteins. The presence of these fragments of the virus (note this is not "live" virus) prompts our immune system to generate protective antibodies to the real thing. Our bodies break down mRNA all the time in normal cellular processes – this is nothing new.
What the transience of the delivery system means is that most of the effects of the mRNA vaccines are expected to be more immediate (sore arm, redness at the site, fever, chills etc.), with no long-term side effects anticipated. A severe allergic response has been reported to occur in some generally within the first 15 minutes, is very rare, and everyone gets observed for that as part of standard vaccine administration. Even with the very uncommon complication of myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining of the heart) seen primarily in young men under the age of 30 following mRNA vaccines, these typically happen within days to 2 weeks and many return to work or school in days. In the 70-year history of pediatric (and adult vaccines), dangerous complications happen in the first two months. There have been millions of adolescents as young as 12 years and thousands in the initial trial of children aged 5-11 who have already received the vaccine and are well beyond the two-month period of observation. There is no biological reason to believe that younger children will have a different long-term side effect profile compared to adolescents or adults.
"Small Sample Size in Kids and the Trial Design"
Although the Pfizer trial in children aged 5-11 was relatively small, it was big enough to give us statistical confidence in assessing safety and efficacy outcomes. Scientists spend a lot of time determining the right sample size of a study during the design phase. On one hand, you want to conduct the study efficiently so that resources are used in a cost-effective way and that you get a timely answer, especially in a fast-moving pandemic. On the other hand, you want to make sure you have enough sample size so that you can answer the question confidently as to whether the intervention works and whether there are adverse effects. The more profound the effect size of the intervention (in this case the vaccine), the fewer the numbers of children needed in the trials.
Statistics help investigators determine whether the results seen would have appeared by chance or not. In this case, the effect was real and impressive. Over 3,000 children around the world have received the vaccines through the trials alone with no serious side effects detected. The first press release reported that the immune response in children aged 5-11 was similar (at one-third the vaccine dose) to the response in the comparator group aged 16-25 years old. Extrapolating clinical efficacy results from immune response measurements ("immunobridging" study) would already have been acceptable if this was the only data. This is a standard trial design for many pediatric vaccines. Vaccines are first tested in the lab, followed by animals then adults. Only when deemed safe in adults and various regulatory bodies have signed off, do the pediatric vaccine trials commence.
Because children's immune systems and bodies are in a constant state of development, the vaccines must be right-sized. Investigators typically conduct "age de-escalation" studies in various age groups. The lowest dose is first tried so see if that is effective, then the dose is increased gradually as needed. Immune response is the easiest, safest and most efficient way to test the efficacy of pediatric vaccines. This is a typical size and design of a childhood vaccine seeking regulatory approval. There is no reason to think that the clinical efficacy would be any different in children vs. adults for a given antibody response, given the experience already in the remainder of the population, including older children and adolescents. Although this was primarily designed as an "immunobridging" study, the initial immunologic response data was followed by real clinical outcomes in this population. Reporting on the outcomes of 2,268 children in the randomized controlled trial, the vaccine was 90.7% effective at preventing symptomatic infection.
"Fear of Myocarditis"
Myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the lining of the heart) have been associated with receipt of the mRNA vaccines, particularly among male adolescents and young adults, typically within a few days after receiving the second dose. But this is very rare. For every million vaccine recipients, you would expect 41 cases in males, and 4 cases in females aged 12-29 years-old. The risk in older age groups is substantially lower. It is important to recognize that the risk of myocarditis associated with COVID is substantially higher. Patients present with new chest pain, shortness of breath, or palpitations after receiving an mRNA vaccine (more common after the second dose). But outcomes are good if associated with the vaccine. Most respond well to treatment and resolve symptoms within a week. There have been no deaths associated with vaccine-associated myocarditis.
In contrast, COVID-associated myocarditis has been associated with more severe cases as well as other complications including chronic symptoms of long COVID. The risk of myocarditis is likely related to vaccine dose, so the fact that one-third the dose of the vaccine will be used in the 5-11 year-olds is expected to correspond to a lower risk of myocarditis. At the lower dose given to younger kids, there has been a lower incidence of adverse effects reported compared to older children and adults who received the full dose. In addition, baseline rates of myocarditis not associated with vaccination are much lower in children ages 5-11 years than in older children, so the same may hold true for vaccine-associated myocarditis cases. This is because myocarditis is associated with sex hormones (particularly testosterone) that surge during puberty. In support of this, the incidence of vaccine-associated myocarditis is lower in 12–15-year-old boys, compared to those who were older than 16 years old. There were no cases of myocarditis reported in the experience to date of 5–11-year-old children in the trials, although the trial was too small to pick up on such a rare effect.
"Optimal Dose Spacing Interval: Longer Than 3 Weeks?"
There is a biologic basis for increasing the interval between vaccine doses in general. Priming the immune system with the first shot and then waiting gives the second shot a better chance of prompting a secondary immune reaction that results in a more durable response (with more T cell driven immune memory). One study from the U.K. showed that the antibody response in people over 80 was more than 3 times higher if they delayed the second dose to after 12 weeks for the Pfizer vaccine instead of the 3 weeks studied in trials. In a study of 503 British health care workers, there were twice as many neutralizing antibodies produced in a longer interval group (6-14 weeks) versus a shorter interval group (3-4 weeks) between doses. However, the safety and efficacy with longer intervals has not been evaluated in the pediatric or other COVID vaccine trials.
In the U.S., the C.D.C. reported that 88 percent of counties are at a "high" or "substantial" level of community transmission. Also, Europe is already experiencing a winter surge of infections that may predict more U.S. winter cases as international travel reopens. During a time of high community virus burden with a highly transmissible Delta variant, relying on one dose of vaccine for several more weeks until the second may leave many more susceptible to infection while waiting. One study from England showed that one dose of the Pfizer vaccine was only 33% protective against symptomatic Delta infection in contrast to 50% for the Alpha variant in adults. There has been no corollary information in children but we would expect less protection in general from one vaccine dose vs. two. This is a particularly important issue with the upcoming holiday season when an increased number of families will travel. Some countries such as the U.K. and Norway have proceeded with only offering older than 12 year-olds one dose of vaccine rather than two, but this was before the current European surge which may change the risk-benefit calculus. There are no plans to only offer one vaccine dose in the U.S. at this time. However a lower dose of the vaccine will likely be studied in the future for adolescents aged 12-15.
For parents worried about the potential risk of adverse effects of two doses of vaccines in their children, it is reasonable to wait 6-12 weeks for the second shot but it all depends on your risk-benefit calculus. There is biological plausibility to pursue this strategy. Although there is no pediatric-specific data to draw from, a longer interval may lengthen immune memory and potentially decrease the risk of myocarditis, particularly in boys. There may only be partial benefit in eliciting protective antibodies after one vaccine dose but only 2-4% of children are hospitalized with COVID once infected, with risk of severe illness increasing if they have comorbidities.
There are also some data indicating that 40% of children have already been exposed to infection naturally and may not need further protection after one shot. However, this percentage is likely a large overestimation given the way the data was collected. Using antibody tests to ascertain previous infection in children may be problematic for several reasons: uncertainty regarding duration of protection, variability in symptoms in children with most having very mild symptoms, and the lack of standardization of antibody tests in general. Overall, if the child has medical comorbidities such as diabetes, parents are planning to travel with their children, if local epidemiology shows increasing cases, and if there are elderly or immunocompromised individuals in the household, I would vaccinate children with two doses as per the original recommended schedule.
Bottom line: Given the time of the year and circulating Delta, I would probably stick with the recommended 3-week interval between doses for now for most children. But if parents choose a longer interval between the first and second dose for their children, I wouldn't worry too much about it. Better to be vaccinated - even if slowly, over time -- than not at all.
Creamy milk with velvety texture. Dark with sprinkles of sea salt. Crunchy hazelnut-studded chunks. Chocolate is a treat that appeals to billions of people worldwide, no matter the age. And it’s not only the taste, but the feel of a chocolate morsel slowly melting in our mouths—the smoothness and slipperiness—that’s part of the overwhelming satisfaction. Why is it so enjoyable?
That’s what an interdisciplinary research team of chocolate lovers from the University of Leeds School of Food Science and Nutrition and School of Mechanical Engineering in the U.K. resolved to study in 2021. They wanted to know, “What is making chocolate that desirable?” says Siavash Soltanahmadi, one of the lead authors of a new study about chocolates hedonistic quality.
Besides addressing the researchers’ general curiosity, their answers might help chocolate manufacturers make the delicacy even more enjoyable and potentially healthier. After all, chocolate is a billion-dollar industry. Revenue from chocolate sales, whether milk or dark, is forecasted to grow 13 percent by 2027 in the U.K. In the U.S., chocolate and candy sales increased by 11 percent from 2020 to 2021, on track to reach $44.9 billion by 2026. Figuring out how chocolate affects the human palate could up the ante even more.
Building a 3D tongue
The team began by building a 3D tongue to analyze the physical process by which chocolate breaks down inside the mouth.
As part of the effort, reported earlier this year in the scientific journal ACS Applied Materials and Interfaces, the team studied a large variety of human tongues with the intention to build an “average” 3D model, says Soltanahmadi, a lubrication scientist. When it comes to edible substances, lubrication science looks at how food feels in the mouth and can help design foods that taste better and have more satisfying texture or health benefits.
There are variations in how people enjoy chocolate; some chew it while others “lick it” inside their mouths.
Tongue impressions from human participants studied using optical imaging helped the team build a tongue with key characteristics. “Our tongue is not a smooth muscle, it’s got some texture, it has got some roughness,” Soltanahmadi says. From those images, the team came up with a digital design of an average tongue and, using 3D printed molds, built a “mimic tongue.” They also added elastomers—such as silicone or polyurethane—to mimic the roughness, the texture and the mechanical properties of a real tongue. “Wettability" was another key component of the 3D tongue, Soltanahmadi says, referring to whether a surface mixes with water (hydrophilic) or, in the case of oil, resists it (hydrophobic).
Notably, the resulting artificial 3D-tongues looked nothing like the human version, but they were good mimics. The scientists also created “testing kits” that produced data on various physical parameters. One such parameter was viscosity, the measure of how gooey a food or liquid is — honey is more viscous compared to water, for example. Another was tribology, which defines how slippery something is — high fat yogurt is more slippery than low fat yogurt; milk can be more slippery than water. The researchers then mixed chocolate with artificial saliva and spread it on the 3D tongue to measure the tribology and the viscosity. From there they were able to study what happens inside the mouth when we eat chocolate.
The team focused on the stages of lubrication and the location of the fat in the chocolate, a process that has rarely been researched.
The artificial 3D-tongues look nothing like human tongues, but they function well enough to do the job.
Courtesy Anwesha Sarkar and University of Leeds
The oral processing of chocolate
We process food in our mouths in several stages, Soltanahmadi says. And there is variation in these stages depending on the type of food. So, the oral processing of a piece of meat would be different from, say, the processing of jelly or popcorn.
There are variations with chocolate, in particular; some people chew it while others use their tongues to explore it (within their mouths), Soltanahmadi explains. “Usually, from a consumer perspective, what we find is that if you have a luxury kind of a chocolate, then people tend to start with licking the chocolate rather than chewing it.” The researchers used a luxury brand of dark chocolate and focused on the process of licking rather than chewing.
As solid cocoa particles and fat are released, the emulsion envelops the tongue and coats the palette creating a smooth feeling of chocolate all over the mouth. That tactile sensation is part of the chocolate’s hedonistic appeal we crave.
Understanding the make-up of the chocolate was also an important step in the study. “Chocolate is a composite material. So, it has cocoa butter, which is oil, it has some particles in it, which is cocoa solid, and it has sugars," Soltanahmadi says. "Dark chocolate has less oil, for example, and less sugar in it, most of the time."
The researchers determined that the oral processing of chocolate begins as soon as it enters a person’s mouth; it starts melting upon exposure to one’s body temperature, even before the tongue starts moving, Soltanahmadi says. Then, lubrication begins. “[Saliva] mixes with the oily chocolate and it makes an emulsion." An emulsion is a fluid with a watery (or aqueous) phase and an oily phase. As chocolate breaks down in the mouth, that solid piece turns into a smooth emulsion with a fatty film. “The oil from the chocolate becomes droplets in a continuous aqueous phase,” says Soltanahmadi. In other words, as solid cocoa particles and fat are released, the emulsion envelops the tongue and coats the palette, creating a smooth feeling of chocolate all over the mouth. That tactile sensation is part of the chocolate’s hedonistic appeal we crave, says Soltanahmadi.
Finding the sweet spot
After determining how chocolate is orally processed, the research team wanted to find the exact sweet spot of the breakdown of solid cocoa particles and fat as they are released into the mouth. They determined that the epicurean pleasure comes only from the chocolate's outer layer of fat; the secondary fatty layers inside the chocolate don’t add to the sensation. It was this final discovery that helped the team determine that it might be possible to produce healthier chocolate that would contain less oil, says Soltanahmadi. And therefore, less fat.
Rongjia Tao, a physicist at Temple University in Philadelphia, thinks the Leeds study and the concept behind it is “very interesting.” Tao, himself, did a study in 2016 and found he could reduce fat in milk chocolate by 20 percent. He believes that the Leeds researchers’ discovery about the first layer of fat being more important for taste than the other layer can inform future chocolate manufacturing. “As a scientist I consider this significant and an important starting point,” he says.
Chocolate is rich in polyphenols, naturally occurring compounds also found in fruits and vegetables, such as grapes, apples and berries. Research found that plant polyphenols can protect against cancer, diabetes and osteoporosis as well as cardiovascular ad neurodegenerative diseases.
Not everyone thinks it’s a good idea, such as chef Michael Antonorsi, founder and owner of Chuao Chocolatier, one of the leading chocolate makers in the U.S. First, he says, “cacao fat is definitely a good fat.” Second, he’s not thrilled that science is trying to interfere with nature. “Every time we've tried to intervene and change nature, we get things out of balance,” says Antonorsi. “There’s a reason cacao is botanically known as food of the gods. The botanical name is the Theobroma cacao: Theobroma in ancient Greek, Theo is God and Brahma is food. So it's a food of the gods,” Antonorsi explains. He’s doubtful that a chocolate made only with a top layer of fat will produce the same epicurean satisfaction. “You're not going to achieve the same sensation because that surface fat is going to dissipate and there is no fat from behind coming to take over,” he says.
Without layers of fat, Antonorsi fears the deeply satisfying experiential part of savoring chocolate will be lost. The University of Leeds team, however, thinks that it may be possible to make chocolate healthier - when consumed in limited amounts - without sacrificing its taste. They believe the concept of less fatty but no less slick chocolate will resonate with at least some chocolate-makers and consumers, too.
Chocolate already contains some healthful compounds. Its cocoa particles have “loads of health benefits,” says Soltanahmadi. Dark chocolate usually has more cocoa than milk chocolate. Some experts recommend that dark chocolate should contain at least 70 percent cocoa in order for it to offer some health benefit. Research has shown that the cocoa in chocolate is rich in polyphenols, naturally occurring compounds also found in fruits and vegetables, such as grapes, apples and berries. Research has shown that consuming plant polyphenols can be protective against cancer, diabetes and osteoporosis as well as cardiovascular and neurodegenerative diseases.
“So keeping the healthy part of it and reducing the oily part of it, which is not healthy, but is giving you that indulgence of it … that was the final aim,” Soltanahmadi says. He adds that the team has been approached by individuals in the chocolate industry about their research. “Everyone wants to have a healthy chocolate, which at the same time tastes brilliant and gives you that self-indulging experience.”
In 1945, almost two decades after Alexander Fleming discovered penicillin, he warned that as antibiotics use grows, they may lose their efficiency. He was prescient—the first case of penicillin resistance was reported two years later. Back then, not many people paid attention to Fleming’s warning. After all, the “golden era” of the antibiotics age had just began. By the 1950s, three new antibiotics derived from soil bacteria — streptomycin, chloramphenicol, and tetracycline — could cure infectious diseases like tuberculosis, cholera, meningitis and typhoid fever, among others.
Today, these antibiotics and many of their successors developed through the 1980s are gradually losing their effectiveness. The extensive overuse and misuse of antibiotics led to the rise of drug resistance. The livestock sector buys around 80 percent of all antibiotics sold in the U.S. every year. Farmers feed cows and chickens low doses of antibiotics to prevent infections and fatten up the animals, which eventually causes resistant bacterial strains to evolve. If manure from cattle is used on fields, the soil and vegetables can get contaminated with antibiotic-resistant bacteria. Another major factor is doctors overprescribing antibiotics to humans, particularly in low-income countries. Between 2000 to 2018, the global rates of human antibiotic consumption shot up by 46 percent.
In recent years, researchers have been exploring a promising avenue: the use of synthetic biology to engineer new bacteria that may work better than antibiotics. The need continues to grow, as a Lancet study linked antibiotic resistance to over 1.27 million deaths worldwide in 2019, surpassing HIV/AIDS and malaria. The western sub-Saharan Africa region had the highest death rate (27.3 people per 100,000).
Researchers warn that if nothing changes, by 2050, antibiotic resistance could kill 10 million people annually.
To make it worse, our remedy pipelines are drying up. Out of the 18 biggest pharmaceutical companies, 15 abandoned antibiotic development by 2013. According to the AMR Action Fund, venture capital has remained indifferent towards biotech start-ups developing new antibiotics. In 2019, at least two antibiotic start-ups filed for bankruptcy. As of December 2020, there were 43 new antibiotics in clinical development. But because they are based on previously known molecules, scientists say they are inadequate for treating multidrug-resistant bacteria. Researchers warn that if nothing changes, by 2050, antibiotic resistance could kill 10 million people annually.
The rise of synthetic biology
To circumvent this dire future, scientists have been working on alternative solutions using synthetic biology tools, meaning genetically modifying good bacteria to fight the bad ones.
From the time life evolved on earth around 3.8 billion years ago, bacteria have engaged in biological warfare. They constantly strategize new methods to combat each other by synthesizing toxic proteins that kill competition.
For example, Escherichia coli produces bacteriocins or toxins to kill other strains of E.coli that attempt to colonize the same habitat. Microbes like E.coli (which are not all pathogenic) are also naturally present in the human microbiome. The human microbiome harbors up to 100 trillion symbiotic microbial cells. The majority of them are beneficial organisms residing in the gut at different compositions.
The chemicals that these “good bacteria” produce do not pose any health risks to us, but can be toxic to other bacteria, particularly to human pathogens. For the last three decades, scientists have been manipulating bacteria’s biological warfare tactics to our collective advantage.
In the late 1990s, researchers drew inspiration from electrical and computing engineering principles that involve constructing digital circuits to control devices. In certain ways, every cell in living organisms works like a tiny computer. The cell receives messages in the form of biochemical molecules that cling on to its surface. Those messages get processed within the cells through a series of complex molecular interactions.
Synthetic biologists can harness these living cells’ information processing skills and use them to construct genetic circuits that perform specific instructions—for example, secrete a toxin that kills pathogenic bacteria. “Any synthetic genetic circuit is merely a piece of information that hangs around in the bacteria’s cytoplasm,” explains José Rubén Morones-Ramírez, a professor at the Autonomous University of Nuevo León, Mexico. Then the ribosome, which synthesizes proteins in the cell, processes that new information, making the compounds scientists want bacteria to make. “The genetic circuit remains separated from the living cell’s DNA,” Morones-Ramírez explains. When the engineered bacteria replicates, the genetic circuit doesn’t become part of its genome.
Highly intelligent by bacterial standards, some multidrug resistant V. cholerae strains can also “collaborate” with other intestinal bacterial species to gain advantage and take hold of the gut.
In 2000, Boston-based researchers constructed an E.coli with a genetic switch that toggled between turning genes on and off two. Later, they built some safety checks into their bacteria. “To prevent unintentional or deleterious consequences, in 2009, we built a safety switch in the engineered bacteria’s genetic circuit that gets triggered after it gets exposed to a pathogen," says James Collins, a professor of biological engineering at MIT and faculty member at Harvard University’s Wyss Institute. “After getting rid of the pathogen, the engineered bacteria is designed to switch off and leave the patient's body.”
Overuse and misuse of antibiotics causes resistant strains to evolve
Adobe Stock
Seek and destroy
As the field of synthetic biology developed, scientists began using engineered bacteria to tackle superbugs. They first focused on Vibrio cholerae, which in the 19th and 20th century caused cholera pandemics in India, China, the Middle East, Europe, and Americas. Like many other bacteria, V. cholerae communicate with each other via quorum sensing, a process in which the microorganisms release different signaling molecules, to convey messages to its brethren. Highly intelligent by bacterial standards, some multidrug resistant V. cholerae strains can also “collaborate” with other intestinal bacterial species to gain advantage and take hold of the gut. When untreated, cholera has a mortality rate of 25 to 50 percent and outbreaks frequently occur in developing countries, especially during floods and droughts.
Sometimes, however, V. cholerae makes mistakes. In 2008, researchers at Cornell University observed that when quorum sensing V. cholerae accidentally released high concentrations of a signaling molecule called CAI-1, it had a counterproductive effect—the pathogen couldn’t colonize the gut.
So the group, led by John March, professor of biological and environmental engineering, developed a novel strategy to combat V. cholerae. They genetically engineered E.coli to eavesdrop on V. cholerae communication networks and equipped it with the ability to release the CAI-1 molecules. That interfered with V. cholerae progress. Two years later, the Cornell team showed that V. cholerae-infected mice treated with engineered E.coli had a 92 percent survival rate.
These findings inspired researchers to sic the good bacteria present in foods like yogurt and kimchi onto the drug-resistant ones.
Three years later in 2011, Singapore-based scientists engineered E.coli to detect and destroy Pseudomonas aeruginosa, an often drug-resistant pathogen that causes pneumonia, urinary tract infections, and sepsis. Once the genetically engineered E.coli found its target through its quorum sensing molecules, it then released a peptide, that could eradicate 99 percent of P. aeruginosa cells in a test-tube experiment. The team outlined their work in a Molecular Systems Biology study.
“At the time, we knew that we were entering new, uncharted territory,” says lead author Matthew Chang, an associate professor and synthetic biologist at the National University of Singapore and lead author of the study. “To date, we are still in the process of trying to understand how long these microbes stay in our bodies and how they might continue to evolve.”
More teams followed the same path. In a 2013 study, MIT researchers also genetically engineered E.coli to detect P. aeruginosa via the pathogen’s quorum-sensing molecules. It then destroyed the pathogen by secreting a lab-made toxin.
Probiotics that fight
A year later in 2014, a Nature study found that the abundance of Ruminococcus obeum, a probiotic bacteria naturally occurring in the human microbiome, interrupts and reduces V.cholerae’s colonization— by detecting the pathogen’s quorum sensing molecules. The natural accumulation of R. obeum in Bangladeshi adults helped them recover from cholera despite living in an area with frequent outbreaks.
The findings from 2008 to 2014 inspired Collins and his team to delve into how good bacteria present in foods like yogurt and kimchi can attack drug-resistant bacteria. In 2018, Collins and his team developed the engineered probiotic strategy. They tweaked a bacteria commonly found in yogurt called Lactococcus lactis to treat cholera.
Engineered bacteria can be trained to target pathogens when they are at their most vulnerable metabolic stage in the human gut. --José Rubén Morones-Ramírez.
More scientists followed with more experiments. So far, researchers have engineered various probiotic organisms to fight pathogenic bacteria like Staphylococcus aureus (leading cause of skin, tissue, bone, joint and blood infections) and Clostridium perfringens (which causes watery diarrhea) in test-tube and animal experiments. In 2020, Russian scientists engineered a probiotic called Pichia pastoris to produce an enzyme called lysostaphin that eradicated S. aureus in vitro. Another 2020 study from China used an engineered probiotic bacteria Lactobacilli casei as a vaccine to prevent C. perfringens infection in rabbits.
In a study last year, Ramírez’s group at the Autonomous University of Nuevo León, engineered E. coli to detect quorum-sensing molecules from Methicillin-resistant Staphylococcus aureus or MRSA, a notorious superbug. The E. coli then releases a bacteriocin that kills MRSA. “An antibiotic is just a molecule that is not intelligent,” says Ramírez. “On the other hand, engineered bacteria can be trained to target pathogens when they are at their most vulnerable metabolic stage in the human gut.”
Collins and Timothy Lu, an associate professor of biological engineering at MIT, found that engineered E. coli can help treat other conditions—such as phenylketonuria, a rare metabolic disorder, that causes the build-up of an amino acid phenylalanine. Their start-up Synlogic aims to commercialize the technology, and has completed a phase 2 clinical trial.
Circumventing the challenges
The bacteria-engineering technique is not without pitfalls. One major challenge is that beneficial gut bacteria produce their own quorum-sensing molecules that can be similar to those that pathogens secrete. If an engineered bacteria’s biosensor is not specific enough, it will be ineffective.
Another concern is whether engineered bacteria might mutate after entering the gut. “As with any technology, there are risks where bad actors could have the capability to engineer a microbe to act quite nastily,” says Collins of MIT. But Collins and Ramírez both insist that the chances of the engineered bacteria mutating on its own are virtually non-existent. “It is extremely unlikely for the engineered bacteria to mutate,” Ramírez says. “Coaxing a living cell to do anything on command is immensely challenging. Usually, the greater risk is that the engineered bacteria entirely lose its functionality.”
However, the biggest challenge is bringing the curative bacteria to consumers. Pharmaceutical companies aren’t interested in antibiotics or their alternatives because it’s less profitable than developing new medicines for non-infectious diseases. Unlike the more chronic conditions like diabetes or cancer that require long-term medications, infectious diseases are usually treated much quicker. Running clinical trials are expensive and antibiotic-alternatives aren’t lucrative enough.
“Unfortunately, new medications for antibiotic resistant infections have been pushed to the bottom of the field,” says Lu of MIT. “It's not because the technology does not work. This is more of a market issue. Because clinical trials cost hundreds of millions of dollars, the only solution is that governments will need to fund them.” Lu stresses that societies must lobby to change how the modern healthcare industry works. “The whole world needs better treatments for antibiotic resistance.”