Two Unicamp research studies in partnership with Washington University are among the eleven initiatives selected in a call for international scientific cooperation aimed at investigating the impacts of the new coronavirus pandemic on public health, the economy and society.
Launched in April by McDonnell International Scholars Academy - network that brings together around 30 top-tier research universities from different parts of the world – the call focused on interdisciplinary research in two areas: public health issues arising from infectious diseases such as covid-19, and the long-term social impact of this and future pandemics. The objective is to carry out research simultaneously in different countries, in the search for more comprehensive answers to the challenges posed by the new coronavirus – the projects will receive up to 50 thousand dollars to start activities, resources that will be managed jointly by the partner institutions.
Covid-19 and pregnancy
Obstetrician Maria Laura Costa do Nascimento, professor at the Department of Tocogynecology at the Faculty of Medical Sciences (FCM) at Unicamp, will conduct research on the consequences of coronavirus infection during pregnancy, focusing on the collection and analysis of samples from the placenta of pregnant women who test positive for Covid-19. The study will be carried out within the Center for Comprehensive Attention to Women's Health (Caism), where currently all women admitted for childbirth are already tested for the disease, regardless of the presentation of symptoms. Professor Indira Mysorekar will do the same at Barnes-Jewish Hospital, located at Washington University, in Saint Louis, in the state of Missouri, United States. They intend to list clinical and laboratory data from at least 40 pregnant women at each university – in addition to the placenta, other biological materials will be analyzed, such as samples of amniotic fluid and umbilical cord blood, babies' respiratory secretions and breast milk. For Maria Laura, the partnership between the two institutions will allow important comparisons to be made between the two countries, which together currently represent almost 50% of confirmed cases of Covid-19 in the world.
“Our objective is to investigate whether there is detectable virus in the placenta and what are the pathways involved in the infection. There are few studies published so far on the possibility of vertical transmission, when the infection passes from mother to baby, which can occur before, during or after birth, through breastfeeding or contact”, he explains. As the placenta is one of the possible routes of intrauterine transmission, the research seeks to understand whether infection of the organ can cause damage through the direct action of the virus, or whether it is the effects of the disease on the mother's body that generate changes in the placenta which, in turn, Sometimes, they can compromise the baby's nutrition or development.
According to Maria Laura, although so far there is no evidence that pregnant women are more susceptible to coronavirus, when infected it is already known that associated complications can occur. “It increases the risk of premature birth, water rupture, and a very serious pregnancy complication, which is today the main cause of maternal death in Brazil: pre-eclampsia (high blood pressure during pregnancy), whose symptoms appear to be associated with Covid-19”.
The central hypothesis of the study is that such complications may be related to the presence in the placenta of a receptor for the coronavirus called angiotensin 2 (ACE2), which, although already widely described in other systems, remains an enigma in the organ. “The studies are controversial: there are studies that show that the placenta expresses this receptor, and there are studies that do not, and perhaps this is even a protective mechanism for vertical transmission, that is, it may be related to the fact that the coronavirus does not generate more serious damage, such as fetal malformation observed in cases of Zika virus infection, for example.” According to the researcher, ACE2 is part of the renin-angiotensin system (RAS), whose activation pathway plays an important role in placental development, angiogenesis (formation of blood vessels) and blood pressure regulation.
To analyze the placentas, a protocol adapted from the research that Maria Laura has been carrying out on the Zika virus will be used, in which samples are taken from various parts of the organ. Unlike the traditional protocol of the Ministry of Health, which recommends the collection of only a random region of the placenta, the method that the researcher learned and improved with her colleagues at Washington University, in addition to increasing the representativeness of samples, also adds additional biosafety measures , which, in the case of Zika, allowed a significant increase in the number of positive diagnoses. “All of this will be important to investigate the coronavirus and also to investigate the risk of vertical transmission”, reinforces the obstetrician.
For Maria Laura, having the project selected in an international research effort on Covid-19 is an important motivation in a scenario that has demanded a lot from everyone working in health care and scientific research. “This shows Unicamp’s academic merit, and the institution’s ability to respond quickly to difficulties. I am happy that the project is also strengthening a partnership that has been going on for many years between the two universities.”
The effects of the pandemic on the care of people with HIV
Another research that Unicamp will develop in partnership with Washington University aims to monitor the impacts of the covid-19 pandemic on the health care of people with HIV, involving patients from specialized centers at each university.
Since 2013, Mônica Jacques de Moraes, infectious disease physician and researcher at the FCM HIV/AIDS Group, has maintained partnerships with the team at the Division of Infectious Diseases at Washington University. Last year, during his last trip to Saint Louis as fellow of the institution, could strengthen relations with infectious disease specialist Elvin Gang and medical anthropologist Shanti Parikh – even before the outbreak of the pandemic, the three had already been putting together joint research to monitor HIV/AIDS public health policies, which was promptly adapted to the call of McDonnel Academy.
“We will analyze the interaction between these two epidemics, that is, whether there has been any harm in the care of people with HIV due to the Covid-19 pandemic, with all the changes in the health system that are occurring at the moment”, he says Monica. She will be responsible for monitoring the approximately 2700 patients treated by Unicamp's HIV/AIDS Outpatient Clinic, while Gang will be responsible for the almost 2 patients in the American university's HIV program (WU ID Clinic). Shanti will work with a sample of patients from each university to carry out a qualitative analysis of the impact of the pandemic, through interviews and other anthropological procedures.
The study aims to analyze different parameters of care for people with HIV before, during and after the outbreak of the pandemic, that is, it will cover the six months prior to February this year, when diagnoses began to be confirmed in both countries, and the six months after the pandemic period, initially established between February and September 2020. “Unfortunately, perhaps this pandemic period will continue for longer in both countries, so we will have to make some adjustments”, admits the researcher.
“There are some quality indicators of HIV care, such as, for example, how many people stopped treatment during the period, how many people were diagnosed and started treatment in each period, how long it took from diagnosis to starting medication, what is the health status of the patient? patient when monitoring began, and also viral load measurements throughout these three periods, which is an indicator of therapeutic success”, explains the researcher. The qualitative part of the research – which at Unicamp will count on the collaboration of the FCM Psychiatry area, especially Professor Paulo Dalgalarrondo – will focus on the patients' experience during the pandemic, that is, whether they were well guided or felt careless during the pandemic, if they had problems accessing treatments, if they were infected or had family members who became ill with the coronavirus, and so on. The researchers estimate that data collection will begin in September, when routine in-person consultations are expected to resume, which were postponed due to Covid-19.
“The interesting thing is that Saint Louis and Campinas have many similarities: they are cities of practically the same size, the number of patients treated in the outpatient clinics of each university is almost the same, as is the profile of the patients treated, generally in the same age group. There are some differences – we have more women, they have more men; and there is a greater number of patients using intravenous substances – but it is a very similar profile, and a very similar type of antiretroviral treatment, which allows research procedures to be well adjusted”, believes Mônica.
In early July, a UNAIDS report, a joint United Nations program on HIV/AIDS, warned that the 2020 goals will not be met and that there is a great risk of the covid-19 pandemic damaging public policies in the area. According to the document, a complete six-month interruption in HIV treatment could cause more than 500 additional deaths in Sub-Saharan Africa by 2021, which would represent a 10-year setback in mortality levels in the region. “Although we are experiencing several setbacks in our country, we have a very successful HIV program, which over the last 30 years we have always been very proud to participate in, because it is a high-level program. The effects of the pandemic will vary from place to place, and UNAIDS is very attentive to the HIV epidemic in Africa, where there may be greater impacts. Here in Brazil we think it will also have an impact, especially in new diagnoses and the beginning of treatment, but we hope it will be something viable to recover from soon after”, comments the infectious disease specialist. According to her, the situation has been worked on by HIV services linked to the Ministry of Health, which have been mobilized since mid-March to establish protocols that guarantee assistance to patients during the pandemic.
At Unicamp, Mônica says that, because of the coronavirus, one of the first measures was to extend the validity of prescriptions, to facilitate access to medicines and continuity of treatment. Furthermore, all HIV patients being monitored had their routine tests checked and were contacted by telephone to receive guidance from the team, which was able to identify cases that required consultation by telephone or in person – only three of them with a positive diagnosis for HIV. covid-19, which, according to the infectious disease specialist, reinforces the evidence that there would not be an increased risk of contamination for these people. “It was a concern that we had, but around the world, HIV clinics are seeing a relatively small number of people with HIV who have had Covid-19. We have also observed that some people who were not taking care of themselves, who were abandoning treatment, due to fear of the pandemic, started taking better care of themselves again,” she notes.
“I think that cooperation between the two universities becomes more solid with a joint project like this. I am very satisfied, as it is a topic that demands answers that we will be able to contribute to finding”, concludes Mônica.
