Translating Science into Survival - St. Jude Children's Research … · 2014-07-09 · GMP, LLC, stands ready to produce the next influenza master vaccine seed virus should an outbreak

Translating Science into Survival

Scientific Report 2014

Behind the CoverThe scientific image on the cover shows mouse lung tissue infected with influenza virus. Staining with hematoxylin and eosin shows the nuclei of individual alveolar cells (purple), and immunohistochemical staining labels the influenza nucleoprotein-1 protein (brown). Influenza viruses infect approximately 600 million children each year, and for those who are immunosuppressed as a result of anticancer therapies, the effects of influenza infection can be even more life threatening. This fact was recognized more than 40 years ago, when St. Jude was establishing and developing its first research programs. In 1968, the influenza research program was initiated with the faculty recruitment of Robert G. Webster, PhD. Today, the program is still growing. Dr. Webster continues to lead international efforts to mon-itor influenza outbreaks around the world in preparation for the next pandemic, and his laboratory is still pursuing questions about how influenza viruses emerge and evolve to infect a wider range of host species. With Richard J. Webby, PhD, and Stacey L. Schultz-Cherry, PhD, Dr. Webster continues to manage the World Health Organizations Collaborating Center and the National Institute of Allergy and Infectious Diseases Center for Excellence in Influenza Research and Surveillance at St. Jude. Other influenza researchers in the Departments of Infectious Diseases and Immunology are investigating immune responses to influenza infection and discovering new treatments for secondary bacterial infections that can develop thereafter. Finally, a highly trained staff in the Hartwell Center for Biotechnology & Bioinformatics and Childrens GMP, LLC, stands ready to produce the next influenza master vaccine seed virus should an outbreak occur.

St. Jude research has played a pivotal

role in improving overall survival of

pediatric patients with cancer from

20% to 80%. Our strength comes

from an unparalleled integration of

basic research and clinical care.

Privileged communication. Copyright 2014 St. Jude Childrens Research Hospital. No part of this communication may be cited, reproduced, stored in a retrieval system, or transmitted by electronic or other means without prior written permission of the Hospital Director and the appropriate investigator.

This Report reflects the activities of St. Jude Childrens Research Hospital during 2013.

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DIRECTORS STATEMENTS 4

CONTROLLING INFLUENZA: 12 FROM IMMUNE FUNCTION TO GLOBAL ACTION

THE REALIZATION OF A NEW 34 MODEL OF GLOBAL PEDIATRIC CANCER CARE

TOWARD IMPROVING TREATMENT 48 AND SURVIVORSHIP OF CHILDHOOD ACUTE LEUKEMIAS

AUTOPHAGY: RECYCLING 68 CELLULAR COMPONENTS IN HEALTH AND DISEASE

SCIENTIFIC HIGHLIGHTS 82

PROGRAMS 96

ACADEMIC DEPARTMENTS 100

BOARDS & EXECUTIVE STAFF 110

Translating Scienceinto Survival


What makes us uniquely important is how we seamlessly integrate unsur-

passed patient care with world-class

research designed to improve both

cure rates and quality of life of the

children we treat. William E. Evans, PharmD Director and Chief Executive Officer


AN EXCEPTIONAL DESIGNATION FOR OUR COMPREHENSIVE CANCER CENTER FROM THE NATIONAL CANCER INSTITUTE (NCI); ANOTHER FACULTY MEMBER, DR. BRENDA SCHULMAN, ELECTED INTO THE NATIONAL ACADEMY OF SCIENCES; SCIENTIFIC DIRECTOR DR. JAMES DOWNING ELECTED INTO THE INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMY OF SCIENCES; A FOURTH CONSECUTIVE YEAR ON THE FORTUNE 100S LIST OF BEST COMPANIES TO WORK FOR; ANOTHER #1 RANKING BY MILLENNIAL SCHOLARS AS THEIR DESIRED PLACE TO WORK; 782 PEER-REVIEWED RESEARCH PUBLICATIONS; AND MORE THAN 260,000 OUTPATIENT ENCOUNTERS ARE INDICATIVE OF THE PRODUCTIVE YEAR WE HAD AT ST. JUDE.

This annual Scientific Report, which is a mere sampling of the many outstanding programs on campus, was developed to give readers a glimpse of advances that were made in the past year. We have highlighted influenza research, the International Outreach Program, leukemia research, and an evolving area of basic science called autophagy. These programs are representative of the broad spectrum of research at St. Jude, which spans from basic science to translational and clinical trials. Collaboration is a hallmark of St. Jude, and the team members featured in this years Report range from postdoctoral trainees to an icon among our faculty, Dr. Robert Webster. Rob came to St. Jude in 1968 as a junior faculty member in the Department of Virology, joining a nascent basic science group chaired by Dr. Alan Granoff. Alan was energetic and entertaining (an amateur actor on the side), and Rob was a calm, serious New Zealander with a clever sense of humor below the surface. These different personalities shared a common belief in St. Jude and a common interest in the emerging science of virology. Rob became interested in influenza while a doctoral student in Australia. He has spent his career at St. Jude unraveling the mechanisms by which influenza viruses migrate around the globe (he discovered it is via birds) and how the influenza genome evolves to become more virulent and communicable. Among his many career highlights was his election into the U.S. National Academy of Sciences in 1997, in the same class as his long-standing collaborator Dr. Peter Doherty, whom Rob recruited to St. Jude years before Peter won the Nobel Prize. For decades, Rob has been a magnet for talent, attracting many outstanding scientists to St. Jude, several of whom are highlighted in this Report.

Work in our Comprehensive Cancer Center spans from discoveries of the genetic origins and predisposition to childhood cancer to innovative new treatments to improve cure rates and the quality of life of our patients. This is nicely illustrated by our leukemia program. Indeed, all of our clinical advances are built upon a foundation of fundamental discoveries, exemplified by research on autophagy and many other discoveries summarized in the Scientific Highlights of this Report. I was not surprised that our Comprehensive Cancer Center received an Exceptional rating after its formal review by NCI last year. Kudos to Cancer Center Director Dr. Richard Gilbertson and his entire team for this extraordinary recognition. Exceptional is a new designation given to only the very best NCI Cancer Centers in recognition of their performance above the former top rating of Outstanding. Richard is the first to say that this recognition is the product of many talented Cancer Center faculty and staff members who do outstanding work and the synergies that emerge from their collaborations. St. Jude remains the only NCI-designated Comprehensive Cancer Center devoted solely to children, serving as a national resource with a global mission. As I complete my tenth and final year as Director and CEO, I am excited about the trajectory of the institution and very much looking forward to returning to the front lines of discovery and translation, the sine qua non for advancing cures. Like Rob Webster and many others, I came to St. Jude as a junior faculty member and never left. I began my career as a researcher and that is how I always hoped to end it. As reflected in this Scientific Report, there is no better place to have such a career than at St. Jude.


James R. Downing, MDScientific Director

We are in a war against cancer with innocent children dying every day.

We must be committed to winning

this war.


ST. JUDES INSTITUTIONAL CULTURE IS ONE OF ITS GREATEST STRENGTHS. WE HAVE GATHERED SOME OF THE GREATEST MINDS IN SCIENCE AND PROVIDED THEM WITH THE BEST TOOLS TO EFFICIENTLY TRANSLATE THEIR DISCOVERIES INTO CLINICAL TRIALS. WHAT UNIFIES OUR DIVERSE GROUP OF INVESTIGATORS IS THE SHARED VISION THAT THROUGH CUTTING-EDGE RESEARCH, WE WILL ADVANCE TREATMENTS AND ULTIMATELY DISCOVER CURES FOR SOME OF THE MOST CATASTROPHIC CHILDHOOD DISEASES.

In this Scientific Report, we present recent progress from our influenza program that involves investigators from the Departments of Infectious Diseases and Immunology. Since 1968, Robert G. Webster, PhD, has been at the helm of influenza studies conducted at St. Jude. His research into the origins of influenza outbreaks and mechanisms of viral reassortment to exploit a wider range of hosts has resulted in more than 700 publications, countless awards, and the enviable moniker flu hunter.

The expertise and international leadership of our flu team is reflected in St. Judes designation as a World Health Organization Collaborating Center in the Global Influenza Surveillance and Response System and as a National Institute of Allergy and Infectious Diseases Center of Excellence in Influenza Research and Surveillance. Working with Dr. Webster to lead these efforts are Drs. Richard J. Webby and Stacey L. Schultz-Cherry from the Department of Infectious Diseases. Both affiliations mandate the same responsibility to respond to emerging influenza threats to public health on a global scale.

In the second feature of this Report, we describe a new operational model that is being adopted by the International Outreach Program (IOP). The IOP strives to advance the treatment of children with cancer in low-income countries, so that they experience outcomes comparable to their counterparts in higher-income countries. By establishing the regional partner networks model, the IOP is extending education and training efforts even farther. The IOP is also working with partner sites to form regional cooperative groups to conduct clinical trials, gain knowledge, and share expertise.

New findings on acute leukemias are conveyed in the third feature. Multidisciplinary teams of oncologists, pathologists, epidemiologists, pharmacologists, and bioinformatics scientists are

elucidating the causes of acute pediatric leukemias, advancing treatments, and ensuring that adult survivors experience good health and high quality of life. Although the survival rate of childhood acute lymphoblastic leukemia is now over 90%, those with high-risk disease still suffer poor prognoses. Thus, investigators are studying the genetic bases of high-risk disease, including familial and ancestral influences on risk. Acute myeloid leukemia has a lower survival rate than that of acute lymphoblastic leukemia, and relapse and refractory disease are still common. Thus, researchers are working to discover more effective treatments for this less common form of pediatric leukemia.

In the last feature, we examine the role of autophagy in health and disease. Autophagy, which literally means self-eating, is a quality-control process that is ongoing in every living cell. Damaged DNA and other components are isolated, broken down, and recycled to maintain cellular health. When autophagy is disrupted, damaged components accumulate and degenerative disease can arise. Several St. Jude groups are studying autophagy. Among them is the laboratory of J. Paul Taylor, MD, PhD, the chair of our most recently established academic department, Cell & Molecular Biology. Dr. Taylor and others are elucidating various forms of autophagy to discover how they cause disease. They are also learning to activate and harness those processes as potential new approaches for the treatment of cancer, autoimmune disorders, and neurodegenerative conditions.

These features and other studies highlighted in this Scientific Report demonstrate not only our progress toward understanding the biological bases of diseases but also our global endeavors to improve healthcare in low-income countries and prevent public health crises such as an influenza pandemic. St. Jude is truly the global leader in the fight against catastrophic diseases of childhood.


Richard J. Gilbertson, MD, PhDComprehensive Cancer Center Director

Cures are born in the minds of the brightest doctors and scientists and

perfected in the clinic.


THE NATIONAL CANCER INSTITUTE (NCI) SUPPORTS THE WORK OF 68 OUTSTANDING INSTITUTIONS STUDYING AND TREATING CANCER IN THE UNITED STATES BY AWARDING A SPECIAL GRANT TERMED THE CANCER CENTER SUPPORT GRANT. FORTY-ONE OF THESE INSTITUTIONS HAVE BEEN DESIGNATED AS COMPREHENSIVE CANCER CENTERS AND ARE RECOGNIZED FOR CONDUCTING ESPECIALLY IN-DEPTH AND INTERACTIVE RESEARCH ACROSS THE FULL SPECTRUM OF BASIC, CLINICAL, AND POPULATION-BASED SCIENCES, AS WELL AS PERFORMING IMPORTANT ROLES IN CANCER EDUCATION AND COMMUNITY OUTREACH. ST. JUDE IS UNIQUE IN THAT IT IS THE ONLY NCI-DESIGNATED COMPREHENSIVE CANCER CENTER FOCUSED SOLELY ON PEDIATRIC CANCERS. FOLLOWING THE 5-YEAR COMPETING RENEWAL OF OUR CANCER CENTER SUPPORT GRANT IN 2013, THE COMPREHENSIVE CANCER CENTER AT ST. JUDE RECEIVED A SCORE OF EXCEPTIONAL THE HIGHEST SCORE AWARDED TO CANCER CENTERS BY THE NCI.

Each year, the St. Jude Comprehensive Cancer Center treats more than 460 new patients with cancer, alongside thousands of patients who are already enrolled on our clinical trials. The 165 members of the Center work together to ensure that each child receives the best possible care and that we learn all we can to reduce the morbidity and mortality associated with childhood cancer. The highest-quality basic and clinical research is conducted via our five interactive programs and 10 shared resources. The goal of this work is to translate the latest understanding of cancer biology into curative therapies with minimal long-term side effects. Over the last 5 years, 32,522 clinical trial enrollments occurred at our Center, of which 56% were to studies initiated by St. Jude Comprehensive Cancer Center investigators. External peer-reviewed trials, many of which are led by Center members, accounted for another 38% of enrollments.

Members of the Hematological Malignancies Program have uncovered novel driver mutations of pediatric leukemias and developed curative treatment protocols for these diseases. Studies of normal tissues and malignancies in the developing brain have enabled members of the Neurobiology & Brain Tumor Program to probe the origins of pediatric brain tumors and integrate their findings into novel clinical trial designs. The processes orchestrating normal and malignant development in peripheral solid tissues are studied by members of the Developmental Biology & Solid Tumor Program, enabling the development of novel treatment approaches for this class of childhood cancers. The Cancer Genetics, Biochemistry, & Cell Biology Programthe newest program in the Cancer

Centerfocuses on fundamental cell processes, including metabolism, protein processing, and cell death. These studies provide important insights into how basic cellular functions are corrupted during tumorigenesis. Our Cancer Prevention & Control Program has galvanized efforts at St. Jude to elucidate the acute and late effects of cancer treatment and reduce their impact on the quality and quantity of life for survivors. Active collaboration among these programs is promoted to ensure the maximum benefit for children with cancer.

The Comprehensive Cancer Center also plays a central role in St. Judes mission to serve as a national resource in the fight against childhood cancer. Several of our members play leading roles in the NCI-sponsored Childrens Oncology Group and Pediatric Brain Tumor Consortium, and our discoveries are rapidly made available to the worldwide scientific community. Our commitment to the dissemination of knowledge is exemplified by the release into the public domain of the whole-genome sequences of more than 800 pediatric cancers generated through the St. JudeWashington University Pediatric Cancer Genome Project. These exciting studies are uncovering previously unknown mutations that drive childhood cancers and might serve as targets for novel therapeutic approaches. The alignment of these and other discoveries with major institutional resources, such as the Department of Chemical Biology & Therapeutics, places the Comprehensive Cancer Center and its members at the forefront of discovery and ensures that we will lead the effort to develop cures for children with cancer long into the future.


Larry E. Kun, MD Clinical Director

Our translational science and integrated therapeutic trials combine with the

strength of our patient care to highlight

the opportunities that are unique for

families seeking care at St. Jude.


CLINICAL ENTERPRISE AT ST. JUDE PROVIDES THE HIGH-QUALITY PATIENT CARE NECESSARY TO SUPPORT INNOVATIVE CLINICAL TRIALS. THE CLINICAL FACULTY AND HIGHLY SKILLED STAFF ARE COORDINATED TO ENSURE OPTIMAL PATIENT CARE AND A UNIQUE LEVEL OF SUPPORT TO OUR PATIENTS AND THEIR FAMILIES.

Throughout last year, we sought to explore and improve our patient care model, reorganize and enhance our Quality Improvement Program, and provide new opportunities that further strengthen our primary care team. We initiated a Quality Improvement Morbidity and Mortality Conference series that highlights challenges in clinical diagnosis and care and emphasizes the value of integrating highly skilled medical specialists, advanced technologies, and dedicated caregivers. We also introduced the Schwartz Center Rounds in which experiences and perceived personal challenges are shared among physicians, nurses, technologists, social workers, and therapists engaged in primary care and patient/family support.

In 2013, we also introduced the concept of targeted patient recruitment. By changing our infrastructure and broadening our approach to accepting new patients, we demonstrated our capability to increase the number of new pediatric oncology patients at St. Jude. Within months, we met and exceeded our targeted acceptance rate. Although sometimes challenging to our clinical systems, our goals of accruing patients to new primary therapeutic protocols investigating solid tumors, leukemia/lymphoma, and brain tumors have been met. We have also increased both the number of new pediatric oncology patients seen at St. Jude and the percentage of those entering novel clinical trials.

To provide the caliber of care necessary to incorporate intensive therapeutic components in clinical trials at diagnosis and unique, detailed, long-term follow-up studies, we have implemented a new strategic relationship with the Department of Pediatrics at the University of Tennessee Health Science Center and Le Bonheur Childrens Hospital. Support from St. Jude has enabled us to jointly attract high-caliber pediatric subspecialists with interests that augment sophisticated patient care and encourage collaborative clinical research in patient populations at St. Jude. We have

demonstrated the value of this relationship in recruiting nationally recognized subspecialty physicians and surgeons in areas key to our interests in pediatric cancer, nonmalignant hematologic diseases, and life-threatening infectious diseases.

Central to the clinical infrastructure are our clinical facilities and advanced technologies. Many of our inpatient units no longer meet our needs to provide comprehensive care with the technologies and comfort that we believe are appropriate. The outpatient clinics are less efficient than one would ideally like due to limited space and adjacencies that no longer provide optimal efficiencies in care. We have invested considerable effort in projecting our needs for inpatient beds and outpatient clinics over the next several years. Using detailed program-by-program and service-by-service plans for the next 5+ years, we have projected our clinical space needs and are now considering relocating inpatient units to the soon-to-be-completed Tower II, which will be an ideal location adjacent to the new surgical suites and intensive care unit. This move will provide modern, well-designed patient rooms with comfortable family rooms and functional patient and family common areas, as well as essential support services. Finally, moving the inpatient units would enable us to renovate the entire Patient Care Center into a modern, more efficient outpatient center, thereby consolidating most of our currently dispersed ambulatory care units and related services.


There are multitudes of health threats to the patient population

at St. Jude. These children must cope with not only their

primary disease but also various side effects of treatment.

One severe side effect is immunosuppression, which results

in an impaired ability to respond to infectious diseases and a

corresponding susceptibility to infection. To respond effectively

to these threats, St. Jude has established several research

programs focused on infections of the respiratory tract and

the immune responses that are initiated as a result of those

infections. A particular historic strength of the institution is its

influenza program. The World Health Organization estimates

that influenza infects as many as 30% of the two billion children

in the world every year.

Influenza research at St. Jude began with the faculty

recruitment of Robert G. Webster, PhD, in 1968. That same

year, an influenza pandemic occurred in Hong Kong, serving

as a stark reminder of the impact that the virus can have on

all sectors of the population, especially children. Influenza

research was further strengthened at St. Jude by the faculty

recruitment of Peter C. Doherty, PhD, who was using influenza

as a model system to increase our understanding of the

mammalian immune response. Although Drs. Webster and

Doherty were both early hires, the programs in influenza

research that they initiated remain strong even today.

CONTROLLING INFLUENZA: FROM IMMUNE FUNCTION TO GLOBAL ACTION


Richard J. Webby, PhD; Jennifer DeBeauchamp-Newman


A LEGACY OF INFLUENZA RESEARCH The unique influenza program at St. Jude largely reflects the seminal work of Robert G. Webster, PhD, who was recruited some 40 years ago by Dr. Alan Granoff, the chair of the Department of Virology at that time. Dr. Granoff and other hospital leaders, including the institutions founder, Danny Thomas, firmly believed that basic science was as essential as applied science and clinical studies in fighting catastrophic diseases. Before coming to St. Jude, Dr. Webster had already made some seminal scientific contributions in the areas of original antigenic sin (the effect of the immune system using immunologic memory to fight infections ineffectively) and the wool dye Coomassie brilliant blue, which is used to stain proteins. With Dr. Graeme Laver (John Curtin Medical School, Canberra, Australia), he developed the first subunit influenza vaccines, the principles of which still guide influenza vaccine development today. When Dr. Webster arrived at St. Jude, the world was in the grips of an influenza pandemic. Mainstream thinking at the time was that influenza pandemics emerged when the circulating seasonal human viruses underwent a severe genetic and antigenic change through mutation. Dr. Webster was not convinced that this was the case. With funding from the National Institute of Allergy and Infectious Diseases (NIAID) and ALSAC, Dr. Webster embarked on a journey to prove an alternative theorythat pandemics are, in fact, the result of animal influenza viruses recombining with human viruses and jumping to humans. After 40 years of research that has been documented in more than 700 publications, inductions into the National Academy of Sciences of the United States and the Royal Societies of London and New Zealand, being awarded the Rose Marie Thomas Endowed Chair in Virology and Molecular Biology, and receiving numerous other awards, Dr. Websters way of thinking has finally been adopted by the rest of the world. It is now clear that his hypothesis was true. Human influenza pandemics do result from virus gene spillover from animals, with the wild birds of the world acting as the major reservoir for influenza viruses. Along the way, Dr. Websters work laid the foundation for much of what we know about influenza ecology. A result of Dr. Websters work was the 1975 invitation from the World Health Organization (WHO) for St. Jude to become a WHO Collaborating Center. Today, St. Jude remains one of six WHO Collaborating Centers within the Global Influenza Surveillance and Response System, and St. Jude is the only Center that focuses solely on influenza viruses at the avianhuman interface.

Although Dr. Websters early work provided us with many of the basic principles of influenza virus ecology, it was perhaps his work after 1997 that has contributed the most to global public and veterinary health. During 1997, Dr. Webster supplied a crucial reagent to a team of Dutch scientists who were working to identify the virus responsible for a fatal infection of a child in Hong Kong. The reagent helped identify the virus as an avian H5N1 virus. That was the first time an avian virus was shown to transmit directly to humans without first reassorting with a human virus. Within months, the virus was detected in an additional 17 persons in Hong Kong, five of whom died. Dr. Webster rallied his laboratory alumni and current staff and students to work with Dr. Kennedy Shortridge (University of Hong Kong). Together, the researchers isolated the responsible influenza pathogen from the live-poultry markets and farms in Hong Kong. This discovery led to the Hong Kong governments decision to close all live-poultry markets, cull associated poultry, and eradicate the virus by the wholesale slaughter of poultry in the region. In 1998, in response to the Hong Kong influenza outbreak, the NIAID awarded St. Jude a contract to conduct H5N1 influenza virus surveillance in Hong Kong, determine the molecular basis of avian-to-human transmission, provide viruses suitable for vaccine development, and produce H5N1-specific protein and antibody reagents for the scientific and medical communities. Arguably the most significant accomplishment of this award was the enhancement of the personnel and research infrastructure at the University of Hong Kong, which has proven time and time again to be essential to responding to emerging viral threats in the region, such as those posed by severe acute respiratory syndrome and H7N9 influenza virus outbreaks. In 2008, the success of Dr. Websters contract encouraged the NIAID to expand its influenza portfolio and create a network of six influenza laboratories that would comprise the Centers of Excellence in Influenza Research and Surveillance (CEIRS). These Centers, of which St. Jude is one, just entered their second 7-year funding period. From 1988 to 2001, Dr. Webster held the Chair of the Department of Virology and Molecular Biology. In that position, he oversaw the expansion of the departments research into areas such as DNA viruses and HIV. Over the years, he has been called many things: flu hunter, the godfather of flu, and an international treasure. His legacy will continue to be felt at St. Jude and in virus research laboratories around the world. He has trained many of the current leaders in the virology research community, and he has built an influenza program at St. Jude that will continue to serve global public health.


The question often asked of me is, Why am I working with influenza in a cancer institute? Its the infectious diseasesthe simple, everday diseases like measles and influenzathat pose serious risks to our children. Studying influenza is a very important component of St. Jude. Robert G. Webster, PhD


IDENTIFYING TRAITS THAT CONFER HIGH PATHOGENICITY TO H5N1 AVIAN INFLUENZA VIRUSES A hallmark of some H5 avian influenza viruses, including those that caused human infection in 1997, is their high pathogenicity. Although it is clear that an accumulation of amino acids at a proteolytic cleavage site in the hemagglutinin (HA) protein is required for pathogenicity, other factors also contribute to this process. In three articles published in the Journal of Virology, investigators from two influenza laboratories in the Department of Infectious Diseases provide further insight. In the first of these studies, Stacey L. Schultz-Cherry, PhD, and her team identified a unique feature of H5 avian influenza viruses that are highly pathogenic in mammalian hoststhey have the ability to productively replicate in macrophages, a class of immune cells that mediates the hosts initial defense against influenza virus infection. The investigators found that this phenotype was attributed to the H5 HA protein itself. The pathogenic viruses were able to overcome an early block that the other viruses were not. Future research in Dr. Schultz-Cherrys laboratory will focus on the intracellular events responsible for high pathogenicity. In the two other studies, which also focused on the role of HA in H5N1 virus pathogenicity, Charles J. Russell, PhD, and members of his team identified the pH at which HA undergoes an irreversible conformational change as a modulator of viral virulence and host adaptation. This irreversible change is required for the fusion of viral and host membranes and subsequent virus entry into the host cell. The investigators found that mutations that lowered the pH at which this HA activation occurred also increased the growth and virulence of the avian influenza virus in mice, while simultaneously decreasing growth, virulence, and transmissibility in ducks and chickens. These data reveal that avian species prefer a high HA-activation pH and mammals prefer a low one. Thus, this molecular property is a key switch in interspecies transmission of H5N1 viruses.

In a follow-up study, Dr. Russells team found that a mutant avian influenza virus in which HA was activated at a lower pH also had enhanced growth in the mammalian upper respiratory tract. Although this mutant virus was not transmissable between ferrets, as is the wild-type H5N1 virus, this enhanced replication in the upper respiratory tract is most likely a required adaptation for this virus to evolve from an avian virus to a mammalian one. Continuing studies in these two laboratories will provide the much-needed data to identify the critical viral factors needed for interspecies transmission and disease caused by H5N1 avian influenza viruses.


ELUCIDATING THE IMMUNE RESPONSE TO INFLUENZA VIRUS INFECTION In April 2009, two influenza viruses were isolated from children in California. Diagnostic tests indicated that the viruses were influenza Apositive, but further viral subtyping could not identify them as either of the commonly circulating strains. Days later, the virus was identified as having a swine origin and a number of other cases were detected, initiating an influenza virus pandemic. In response to this pandemic, Paul G. Thomas, PhD (Immunology), and Richard J. Webby, PhD (Infectious Diseases), received funding from the NIAID to initiate a program to investigate how infected individuals were responding immunologically to the new virus. In collaboration with Miguela A. Caniza, MD (Infectious Diseases), and Dr. John DeVincenzo and his team at Le Bonheur Childrens Hospital (Memphis, TN), Drs. Thomas and Webby initiated a clinical study of children and their family contacts. This population was selected because children are at increased risk of severe influenza infection. Children and their families coming into the Emergency Room at Le Bonheur were approached for enrollment. Nasal washes and blood samples were collected from each participant over time, and virologic and immunologic measurements were taken.

In the American Journal of Respiratory and Critical Care Medicine, Dr. Thomas and Postdoctoral Fellow Christine M. Oshansky-Weilnau identified for the first time an immunologic signature that predicts the clinical outcome of infection. This signature was independent of the amount of virus present and age at diagnosis, two markers that have historically been considered important. The team measured several parameters of the infection and response in 84 participants with influenza infection. Viral load and a plethora of immune cytokines and chemokines were measured in nasal washes and matching serum samples. Participants or their caregivers, as appropriate, documented symptoms daily, providing a measure of disease severity. Of the 84 infected participants, 19 were hospitalized and four required intensive care.

Christine M. Oshansky-Weilnau, PhD; Paul G. Thomas, PhD


After analyzing the data with investigators at the Fred Hutchinson Cancer Research Center (Seattle, WA), the team found that viral load was not correlated with clinical symptoms or hospitalizations. This was the first clue that influenza infection may be immunologically mediated. A correlation of age with hospitalization and an inverse correlation of age with local inflammation supported this hypothesis. The team then concentrated on a subset of 11 cytokines to identify whether they were better predictors of disease outcome. The levels of the innate immune cytokines interferon 2 and monocyte chemotactic protein 3 in nasal washes were correlated with the severity of upper and lowerrespiratory tract infections and total symptoms. The levels of interleukin-6 and vascular endothelial growth factor in the same samples were positively correlated with upperrespiratory tract symptoms. Signatures in serum were also correlated with symptom severity. The team then examined nasal washes and blood samples for the presence of three subpopulations of monocytes that are essential to the innate immune response. Nasal washes from the younger participants contained more CD14+/CD16 monocytes, whereas those from older participants contained more CD14lo/CD16+ monocytes. The subset of CD14+/CD16 cells was positively associated, whereas the CD14lo/CD16+ population was negatively associated, with cytokine levels. Thus, the age-associated increases in specific inflammatory markers and subsequent disease are reflected in the recruitment of specific innate immune cells to the site of infection. The authors concluded that the enhanced inflammation seen in young children with influenza is an intrinsic property of their immune response rather than an inability to clear the invading virus. Also, a specific profile of cytokines, rather than general inflammation, predicts clinical outcome. This work provides insight into the disease susceptibilities of children and reveals new approaches to manipulate the components of the immune response to reduce disease severity and enhance survival. Finally, this study opens up the possibility of designing vaccines to induce optimal immune responses.

Figure. Cell sorting analysis revealed that the monocyte population circulating in the blood (A) differed from that at the site of infection (B). An inclusion gating strategy was used to define CD14+ and CD16+ populations. Red plot indicates patrolling CD14lo/CD16+ monocytes; green plot indicates double-positive cells; and blue plot indicates inflammatory CD14+/CD16 monocytes. Patrolling monocytes at the site of infection were associated with reduced levels of cytokine production, and inflammatory monocytes were associated with increased levels. Reprinted with permission of the American Thoracic Society. Copyright 2014 American Thoracic Society. Oshansky CM et al/2014/Mucosal immune responses predict clinical outcomes during influenza infection independently of age and viral load/Am J Respir Crit Care Med/189/44962. Official Journal of the American Thoracic Society.

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IMPROVING CROSS-PROTECTIVE IMMUNITY TO LETHAL INFLUENZA VIRUS INFECTIONS Designing new vaccines against emerging influenza viruses is complicated by the fact that the dominant immune response, which is targeted by the conventional flu shot, is mounted against hemagglutinin (HA), the most variable influenza virus protein. A major push in the field has been to produce vaccines that induce more cross-reactive immunity by identifying more conserved vaccine antigens or by altering the response to other regions of the virus. In Nature Immunology, a team of investigators led by Maureen A. McGargill, PhD (Immunology), reported their discovery that rapamycin, an immunosuppressive drug that inhibits the serine-threonine kinase mTOR during influenza immunization, improved cross-protective immunity by altering the immune response. On the basis of data linking mTOR inhibition with rapamycin and an enhanced memory CD8+ T-cell response, Dr. McGargill and colleagues hypothesized that rapamycin may enhance the cross-reactivity of influenza vaccines. This hypothesis was based on seminal work from the laboratory of Peter C. Doherty, PhD (Immunology), which showed that CD8+ T cells are protective against multiple influenza virus subtypes.

To test their hypothesis, Dr. McGargills team immunized mice with an H3N2 virus with or without rapamycin; 4 weeks later, they challenged the mice with an H5N1 virus. Mice given the rapamycin fared better and were more protected than those that did not receive the drug. Similar levels of cross-protection were observed against challenges with other influenza virus subtypes. Consistent with the literature, the rapamycin-treated mice had a more robust CD8+ T-cell response to the immunization and viral challenge. However, depletion of these cells showed that they were not required for cross-protection. Thus, the researchers sought to identify the true underlying mechanism of rapamycin-mediated protection.

Rachael Keating, PhD; Maureen A. McGargill, PhD


Unlike their CD8+ counterparts, CD4+ T cells were required for rapamycin-mediated protection; they were necessary during the primary immune response (immunization). This finding suggested that CD4+ T cells may alter the antibody response. Experiments using B celldeficient mice and passive transfer of antibodies confirmed this notion. Using standard assays, Dr. McGargills team was unable to detect differences in neutralizing antibodies in the absence or presence of rapamycin. In contrast, an ELISA assay to measure antibodies specific for all viral proteins showed an increase in influenza-specific IgM antibodies in the rapamycin-treated mice following immunization. The elevated IgM levels were accompanied by a decrease in lymph node germinal centers and IgG antibodies.

In collaboration with Dr. Tomer Hertz (Fred Hutchinson Cancer Research Center), the researchers also showed that rapamycin-treated mice produced antibodies of different specificities than those produced by control animals. Thus, rapamycin treatment protected mice from a lethal secondary influenza infection by altering the antibodies that had been generated during vaccination such that the proportion of influenza-specific antibodies that were IgM (rather than IgG) was increased, and antibodies of unique specificities were generated.

These data shed light on the types of antibodies that provide superior protection against multiple subtypes of influenza and a novel means to enrich the generation of these cross-reactive antibodies, which are important steps toward generating a universal influenza vaccine.

PBSPBSPBSPBSPBSPBSPBSPBSPBSPBSRAPRAPRAPRAPRAPRAPRAPRAPRAPRAP

A IgM responses

0.2 0.4 0.6 0.8

PBSPBSPBSPBSPBSPBSPBSPBSRAPRAPRAPRAPRAPRAPRAPPBSRAPPBSRAPRAP

B IgG responses

0.2 0.4 0.6 0.8 1.0 1.2

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Figure. Rapamycin alters the antibody repertoire. Clustering dendrograms of the patterns of IgM (A) and IgG (B) antibodies in serum following influenza infection and treatment with either phosphate-buffered saline (PBS, blue) or rapamycin (Rap, red). (C) Structures of the hemagglutinin protein from the Vn1203 influenza strain (H5N1) with the positions of the antigens that displayed differential antibody binding shown. 2013 Keating R et al


Robert G. Webster, PhD; Stacey L. Schultz-Cherry, PhD; Richard J. Webby, PhD


RESPONSE TO AN EMERGING PANDEMIC THREAT IN CHINA The expertise, infrastructure, and resources that St. Jude provides the influenza community is reflected in its designation as a WHO Collaborating Center and as an NIAID CEIRS site. At St. Jude, these programs are led by Drs. Webby and Schultz-Cherry. A key activity associated with both of these affiliations is our role in national and global responses to emerging influenza virus threats. This response was put to the test in early 2013, when zoonotic infections (i.e., human infections resulting from contact with infected animals) were identified in China. The influenza virus in question, an H7N9 strain, had never been seen in humans. Questions of immediate public health importance were quickly posed. What is the most likely pathogenic path of the virus? What are its transmission profiles? What are the most likely animal reservoirs? Answers to these questions were required to guide field investigations, understand the epidemiology of the emerging situation, and test intervention strategies. A collaborative study among members of Dr. Webbys laboratory, those of Dr. Yi Guans laboratory (University of Hong Kong and Shantou Medical School), and staff at the China Center for Disease Control was the first to identify the phenotypic properties of the H7N9 viruses. Of note, Dr. Guan is an alumnus of Dr. Websters laboratory.

The study, which appeared in the journal Science, demonstrated that the virus had a relatively high transmission potential, which predicted a high number of human cases in the ensuing weeks. At the time, 130 human infections had been confirmed and 40 deaths had occurred. The study also showed that the virus was unlikely to have evolved in swine, as some scientists had hypothesized. Instead, poultry was more likely the source for human infection. Although doubt was cast on the swine-origin theory for zoonotic infection of the H7N9 virus by showing that the virus could not transmit among swine, the study demonstrated that the H7N9 influenza virus can at least replicate in them, suggesting that the virus poses a threat beyond the initial outbreak.


Following the described observations, Dr. Webster and Postdoctoral Fellow Jeremy C. Jones used a tissue-explant system to further examine the ability of the H7N9 influenza virus to replicate in swine. In the Journal of Virology, they reported that three representative human H7N9 viruses replicated in explants derived from tracheal tissue or lung tissue of swine. Immunostaining of the tissues showed that the H7N9 viruses replicated in the epithelium of the tracheal tissue and were largely restricted to the bronchi of the lung tissue. Drs. Webster and Jones concluded that although the currently circulating H7N9 viruses do not appear to be well adapted to swine, they at least have the capacity to replicate in that intermediate host. This increases the virus opportunity to further adapt by acquiring new mutations or gene segments that may enhance human-to-human transmissibility. Therefore, these viruses continue to pose a threat to public health.

Further evidence that poultry were the most likely source of the recent human H7N9 pandemic was published in Nature. Again collaborating with Dr. Guans group in China, Drs. Webby and Webster showed that the H7N9 virus was most likely a recent reassortant between viruses from wild birds and an H9N2 virus that is endemic in poultry in the region. The researchers sequenced a large number of viruses collected from live-bird markets over the years, many of which were collected under the St. Jude CEIRS funding. This study not only provided a roadmap for the genesis of the zoonotic virus but also showed that the virus was prevalent in markets throughout a large geographic region. The study also identified a closely related H7N7 virus that had the ability to infect mammals. In addition to discerning the basic properties of the virus, the St. Jude flu team was called upon to provide information and reagents to improve the clinical management of the disease. A crucial component of this response was the generation and distribution of a vaccine seed virus in collaboration with the Childrens GMP, LLC, and the Hartwell Center for Biotechnology & Bioinformatics. Using reverse-genetics technology developed in Dr. Websters laboratory, the Childrens GMP pieced together an attenuated vaccine seed virus from an H7N9 virus isolated from one of the first human cases. Once produced, the seed virus was tested by the flu team and staff in the Hartwell Center and then made available to vaccine manufacturers and other interested parties via the WHO.

Poultry H9N2SH-F/98 lineage virus

Eurasian wildbird virus

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Eurasian wildbird N7 virus

Eurasian wildbird H7 virus

Eurasian wildbird N9 virus

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Possible H7N9 precursor in China

Figure. Schematic of the evolutionary pathways of the H7N9 and H7N7 influenza viruses. The ovals represent virus particles, and the bars represent the eight genes. Reassortment events are indicated by the colors of the genes in the descendant viruses (lower rows), which indicate the source virus (top row). Broken bars indicate a deletion, and the broken oval indicates a hypothetical reassortant virus. 2013 Lam TTY et al

Robert G. Webster, PhD; Jeremy C. Jones, PhD


SEQUENCING AND PRODUCING A MASTER VIRAL SEED St. Jude has been providing vaccine seed viruses against influenza viruses of pandemic potential since the H5N1 viruses re-emerged in humans in the early 2000s. Few international institutions participate in such activities because of the expertise and infrastructure required. The basis of St. Judes success in this endeavor is a translational research culture and strong collaborative environment at our institution. The influenza program works with staff in the Hartwell Center for Biotechnology & Bioinformatics and Childrens GMP, LLC, to generate, sequence, and produce vaccine seed viruses. Production of the H7N9 vaccine seed virus started, as had others in the past, with the confirmation of multiple human cases and a sense of enhanced urgency. The powerful sequencing resources in the Hartwell Center and the efficient production resources in the GMP responded in kind. Using genetic material synthesized from the published H7N9 sequences, investigators in the influenza virology laboratories generated expression plasmid clones. The sequencing groups in the Hartwell Center then confirmed the accuracy of those agents. The Hartwell Center contains two sequencing laboratories: The High Throughput Sequencing Laboratory, which uses Sanger chemistry methods to analyze approximately 200,000 samples per year, and the Genome Sequencing Facility, which uses state-of-the-art next-generation technologies to provide genome-wide sequence analysis. The latter group has generated more than 16 Tb of data to date. After sequencing, the plasmids were transferred to the GMP building, which houses a Biosafety Level3 production suite. This suite has been approved by the U.S. Drug Administration to handle the H5N1 vaccine seeds, which are considered select agents until specifically excluded (following submission of a data package to the USDA/CDC select agent program). Mike Tillman, manager of Childrens GMP Manufacturing, and his team of Kimberly Berg and Rhonda Cooper, transfected the

H7N9-expression plasmids and six other plasmids into VERO cells to generate the master viral seed under current good manufacturing practices in less than 6 weeks. This process, which has been optimized over the years, resulted in an attenuated master viral seed suitable for open distribution to vaccine manufacturers and subsequent vaccine production should it be warranted. The current epidemiology of H7N9 influenza has not yet warranted such action, but preparation is paramount. In the meantime, St. Jude investigators continue to closely monitor the evolution of the virus, and the Hartwell Center and Childrens GMP groups remain poised, as always, to respond with enhanced urgency.

Dainel Devine, PhD; Victor Kelley, PhD


OSELTAMIVIR IS EFFECTIVE AGAINST THE H7N9 INFLUENZA VIRUS Antiviral drugs are essential to the clinical manage-ment of influenza. The frontline defense against an emerging influenza virus is the neuraminidase inhibitor class of antiviral drugs, particularly oseltamivir. Although we have expertise in treating influenza viruses that express the N1 or N2 neuraminidases, we have no experience in treating N9 viruses. In response to the recently emergent H7N9 zoonotic virus in China, two members of Dr. Websters laboratory, Postdoctoral Fellow Tatiana Baranovich and Elena Govorkova, MD, PhD, developed a mouse model of acute respiratory distress syndrome to test the efficacy of oseltamivir in reducing morbidity and mortality of the disease. In The Journal of Infectious Diseases, the researchers reported results from testing 12 avian N9 viruses and three human N9 viruses. All the viruses were as susceptible to oseltamivir as are typical seasonal human influenza viruses. Their other main finding was that the efficacy of the drug was better when treatment was started 24 hours after infection; efficacy decreased substantially when antiviral therapy was delayed by 48 hours. Although the number of human H7N9 cases declined with the closure of the live-poultry markets in China, the subsequent reopening of those commercial centers coincided with a second wave of human H9N7 influenza infections. The St. Jude flu team continues to monitor those markets for the virus.

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Figure. Delaying antiviral treatment hinders survival in mice infected with a lethal dose of H7N9 influenza. Oseltamivir therapy (5, 20, or 80 mg/kg per day) was initiated at 24 h (A), 48 h (B), or 72 h (C) postinfection. Sterile water was used as placebo treatment. Baranovich T et al, The neuraminidase inhibitor oseltamivir is effective against A/Anhui/1/2013 (H7N9) influenza virus in a mouse model of acute respiratory distress syndrome, J Infect Dis, 2014, 209, 134353, with permission from the Infectious Diseases Society of America

Elena Govorkova, MD, PhD; Tatiana Baranovich, MD, PhD


INFLUENZA VIRUS AND PNEUMOCOCCUS: A DEADLY COMBINATION On its own, the influenza virus can cause severe disease and death. Secondary bacterial infection, a common complication of influenza infection, can result in enhanced pneumonia, which is most likely the actual cause of many deaths attributed to influenza. Jonathan A. McCullers, MD (Infectious Diseases), and his team are investigating the synergistic action of influenza virus and pneumococcus. Understanding the pathogenesis of secondary bacterial pneumonia and developing effective treatments for this complication has the potential to greatly reduce the impact of influenza on public health. One of the fundamental unknowns about the interaction between these pathogens is the mechanism by which the primary viral infection sets up the host for a robust secondary bacterial infection. In The Journal of Immunology, Drs. McCullers and Thomas and Postdoctoral Fellow Hazem Ghoneim identified a crucial immune cell that ap-pears to be a key player in this process. The team used a novel arsenal of tools to profile immune cells in the lungs of mice infected with influenza virus. They found that during the first week postinfection the population of alveolar macrophages (AMs) in the lung declined more than 90% via a necrotic process. The number of AMs then rebounded during the second week postinfection. The investigators noted that the time of peak AM depletion coincided with the optimal time to establish a secondary bacterial infection. Thus, they proposed that a direct cause-and-effect relation occurs in this system.

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Figure. Influenza infection kills resident alveolar macrophages (AMS). (A) The total number of dead cells was measured in samples of broncheoalveolar lavage fluid obtained before infection with influenza and at 1, 3, and 5 days postinfection. (B) Diff-Quikstained macrophages in broncheoalveolar lavage fluid from mock- or influenza-infected mice at 3 days postinfection. Original magnification, 500. 2013 Ghoneim HE, et al, Depletion of alveolar macrophages during influenza infection facilitates bacterial superinfections, J Immunol, 2013, 191, 12509

In support of this theory, Dr. McCullers and colleagues showed that the clearance of pneumococcus from the lungs of influenza-infected mice at early time points was significantly impaired compared to that seen in mock-infected animals. The magnitude of this impairment was correlated with the level of AM depletion, thereby providing further evidence that the lack of AMs is responsible for this impairment. In addition, accelerating the replenishment of AMs via local administration of granulocyte macrophage colonystimulating factor accelerated pneumococcus clearance. This finding corroborated the conclusion that influenza virus primes the lung for secondary bacterial infection by altering cellular innate immunity.

Using a number of parameters empirically derived from their murine coinfection model, Postdoctoral Fellow Amber M. Smith, a member of Dr. McCullers laboratory, developed a mathematical model that identified impaired AM function as a dominant mechanism in the disease course of secondary pneumonia. This work was a collaboration involving investigators at the Los Alamos National Laboratory (Los Alamos, NM), University of Utah (Salt Lake City, UT), Faculty of Medicine University of Lisbon (Portugal), and University of Melbourne (Australia).

In PLoS Pathogens, the team also reported the previously unrecognized rebound in influenza viral titers after secondary bacterial infection as an important factor in disease synergy. The authors hypothesized that this rebound was caused by an enhanced release of virus from infected cells through the action of bacterial neuraminidases. By identifying AM depletion and virus rebound as critical factors underpinning the enhanced disease, the investigators have provided targets for potential intervention strategies.


Jonathan A. McCullers, MD


Hazem Ghoneim, PhD Amber M. Smith, PhD; Jonathan A. McCullers, MD


ADJUNCT CORTICOSTEROID THERAPY IMPROVES THE OUTCOME OF SEVERE SECONDARY BACTERIAL PNEUMONIA The importance of the innate immune response in secondary bacterial pneumonia was highlighted in another publication from Drs. Ghoneim and McCullers that appeared in The Journal of Infectious Diseases. In earlier studies, Dr. McCullers group had confirmed a clinical observation in a mouse model of secondary infection. The observation was that although treatment with the antibiotic ampicillin cleared secondary bacterial pneumonia, it had little impact on the clinical course. The murine studies showed that this was attributed to rapid bacterial cell lysis, subsequent release of pathogen-associated molecules, and an aberrant proinflammatory response. The prognosis of mice treated with a less lytic antibiotic was improved but still suboptimal. With these data in hand, the researchers hypothesized that administering adjunct corticosteroid therapy with antibiotic treatment would improve outcome by reducing the inflammatory environment. To test this theory, they treated mice with different combinations of ampicillin and the corticosteroid dexamethasone as soon as the mice showed symptoms of severe secondary bacterial pneumonia (i.e., at onset of pneumonia) to mimic the clinic scenario. The majority (70%) of mice treated with both agents survived, but none of those treated with only ampicillin did. The authors cautioned that the timing of dexamethasone administration is crucial. Administration of the corticosteroid during the early stages of the viral infection enhanced the subsequent bacterial pneumonia, even when ampicillin was given at the time of pneumonia development. Drs. Ghoenim and McCullers attributed this result to an impaired immune response to the virus and subsequent delayed viral clearance. The importance of this finding is that some have suggested corticosteroid as a treatment option for severe primary viral pneumonia; these data suggest that this approach should be considered with extreme caution. The authors conclude that corticosteroid use in conjunction with antibiotic use may have clinical benefit in severe cases of secondary bacterial pneumonia, but care must be given to timing the delivery of the agent.

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Figure. Adjunct corticosteroid improves outcome in mice receiving an antibiotic to treat secondary pneumococcal pneumonia after influenza infection. (A) Bioluminescence images of mice with mild or severe secondary pneumonia prior to ampicillin treatment. (B-C) The survival rates of ampicillin-treated mice that received dexamethasone (blue) were better than those that received mock therapy (black). Dexamethasone rescued mice with severe pneumococcal pneumonia (B) and improved survival in those with mild (C) disease. Ghoneim HE, McCullers JA, Adjunctive corticosteroid therapy improves lung immunopathology and survival during severe secondary pneumococcal pneumonia in mice, J Infect Dis, 2014, 209, 145968, with permission from the Infectious Diseases Society of America


CONCLUSION

Virologists and immunologists at St. Jude and

collaborating research centers are working to

increase our understanding of the epidemiology

of influenza viruses, develop better treatments

to minimize their effects in infected individuals,

and continue surveillance to ultimately prevent

potential catastrophic public health crises

caused by an outbreak of the disease.


Each year, 160,000 children across the globe receive a

diagnosis of cancer. Of those, 90,000 (56%) will die of the

disease. This burden has been borne, to a great extent, by

countries that are ill equipped to effectively treat this complex

disease. The International Outreach Program was established

in 1998 to address this disparity by bringing the educational,

structural, and physical resources of St. Jude Childrens

Research Hospital to those regions in need. Although many

deficits are magnified in low- to middle-income countries,

healthcare deserts exist all over the world, and St. Jude

remains committed to identifying those regions and addressing

their needs.

THE REALIZATION OF A NEW MODEL OF GLOBAL PEDIATRIC CANCER CARE


BUILDING INTERNATIONAL PARTNERSHIPS TO IMPROVE CHILDHOOD CANCER OUTCOMES The International Outreach Program (IOP) has focused its approach over the past 16 years on a point-to-point model of partnerships that is referred to as twinning. Using this approach, the Program successfully launched 22 St. Jude IOP partner sites in 15 countries, and those centers have markedly improved the level and quality of care for childhood cancer in those regions. As we have gained a greater understanding of the characteristics of individual sites, we have recognized many factors, such as median-income level, that can be used to stratify the likelihood of abandonment of treatment. On the basis of factors such as this and personal knowledge of site-specific issues that impede effective health care, our partners have been engaged in initiatives to specifically address key problems and deficits such as abandonment of treatment, gaps in care, and shortfalls in staff training. Many of the interventions implemented by the IOP have been based on observations of the level of care available and the problems that individual sites face in delivering that care. These observations were made by IOP physicians and staff during onsite visits to the partner centers or via online patient care meetings. The strong personal relationships formed between IOP faculty and staff and their counterparts at IOP partner sites have been essential to initiating partnerships, implementing the healthcare interventions needed, and making the twinning approach so successful.

A NEW APPROACH TO EXPAND INTERNATIONAL OUTREACH EFFORTS Although the twinning approach has yielded significant dividends over time, in terms of improving care in the pediatric cancer clinics of our partner sites, the key require-mentone-on-one interactionis also its liability. As the global footprint of the IOP increases, the one resource that has become the most valuable and scarce is the individual IOP staff member. Whether it is a physician consulting online to review individual patient cases and provide guidance or a nurse visiting a partner site to discuss nursing care, that IOP member becomes the rate-limiting step, the point of constriction for further progress and growth. This lack of scalability and sustainability of the twinning approach has ultimately driven the IOP to seek another model for operation and growththe regional partner network.


Matthew J. Krasin, MD; Terrence L. Geiger, MD, PhD


Under the leadership of Terrence L. Geiger, MD, PhD (Pathology), and Matthew J. Krasin, MD (Radiological Sciences), the IOP is now transitioning to a regional partner network model of outreach that will connect our partner sites to each other, so that the strengths of one site will be used to reduce the weaknesses of another, and the capabilities and skills of one center may support or improve the level of care in a region. This transition has already begun at our partner sites and in regions across the globe. Some changes have been intentional, some out of necessity, and some because of long-standing successes of this networked approach that have been demonstrated in other fields. In 2013, St. Jude marked the inflection point in this transition. The benefits of employing a regional partner network were recognized, and evolution toward this new model was initiated. There is much work to be completed before the IOP is aligned to undertake significant expansion, but while this foundation is being prepared, many of our partners and other healthcare centers in those regions are benefiting from their new regional partner networks.

THE OFFICE OF GENERAL COUNSEL PROVIDES LEGAL SUPPORT TO THE IOP Although much of IOPs work is performed beyond the walls of St. Jude and in other countries, the Program relies heavily on the Office of General Counsel for diverse legal services. Two members of the legal staff, McGehee Marsh, JD, PhD, and John Bailey, JD, work with IOP staff to establish formal contracts with every partner site. Although the IOP staff views these contracts as a means for distributing knowledge and resources aimed to cure children with cancer, our legal staff ensures that the work is conducted safely and legally.

The IOP deploys services that enable online educational meetings and help manage patient care data from our partner sites. In addition, through the International Visitors Program (IVP) we bring international visitors to the St. Jude campus and allow them access to our research and clinical areas. The legal staff supports these efforts by ensuring that IOP products and services are protected and that international trade statutes are followed. To protect the patients and staff at St. Jude, the legal staff ensures that IVP participants are credentialed and legitimate healthcare professionals.

McGehee Marsh, JD, PhD; John Bailey, JD


AHOPCA: A NETWORK AND COOPERATIVE PEDIATRIC ONCOLOGY TREATMENT GROUP The Asociacion de Hemato-Oncologa Peditrica de Centro Amrica (AHOPCA) was one of the first organizations formed across low- to middle-income countries in Central America to address the disparity in pediatric cancer care at their hospitals and cancer clinics. Hospitals in Guatemala, Honduras, El Salvador, Nicaragua, and Costa Rica were the initial members, all sharing a regional location and language. Although this organization has provided educational and training opportunities to healthcare providers in those countries for years, the most important achievement of the AHOPCA is its implementation of multi-institutional therapeutic protocols. This unique feature of the AHOPCA sets it apart from other groups or networks. Under IOP leadership provided by Monika L. Metzger, MD, MSc (Oncology), the AHOPCA provides a framework for institutions to come together to discuss not only how to treat individual pediatric patients but also how to best treat specific diseases. Since 2000, common therapeutic regimens or protocols for 11 different pediatric cancers have been implemented through the AHOPCA. Several of the AHOPCA protocols have been published and presented at meetings hosted by international societies (e.g., the American Society of Hematology, International Society of Paediatric Oncology, and International Symposium on Childhood Adolescent and Young Adult Hodgkin Lymphoma). These activities have led to invitations for the local principal investigators to visit other pediatric oncology centers, thereby further expanding their professional experience.

The success of the AHOPCA can be measured particularly by its independent recognition beyond pediatric oncologists in Latin America. When St. Jude experts are consulted about some of the diseases treated by the AHOPCA (e.g., Hodgkin lymphoma, non-Hodgkin lymphoma, Wilms tumor), they often refer those requests to AHOPCA members for discussion via established Web-based conferences. Thus, those cases are being managed mainly by our AHOPCA colleagues, further expanding their recognition as leaders in the field.

Monika L. Metzger, MD, MSc


Funding for much of the work in the AHOPCA comes from St. Jude, and much of the clinical leadership comes from the IOP faculty. Although the size of the typical Central American country may seem small, the impact of this effort has been substantial: more than 12,000 children have been treated on AHOPCA-funded protocols since 2000.

The success of this organization demonstrates that a cooperative therapeutic group, even in low- to middle- income countries, can substantially improve the care of children with cancer in those regions. Ultimately, the IOP will deploy this approach across other regions and partner sites, once adequate regional partner networks are established. In this manner, the IOP will ensure that therapeutic regimens are appropriate for each regional partner and that the better disease outcomes we expect for children with cancer in high-income countries are realized for those in low-income countries as well.

MANAGING CLINICAL DATA FOR THE IOP AND PARTNER SITES Without clinical data and other key information, the IOP would be directionless, attempting to improve cures without knowing the etiologies of treatment failures. The IOP approaches this challenge by organizing, evaluating, and securely storing multitudes of data from our partner sites. Chief Medical Information Officer Andrs Sablauer, MD, PhD (Radiological Sciences), and a team of information science experts provide the essential service of ensuring that the IOP safely secures and appropriately manages critical data that our multiple international partners have entrusted to us.

Andrs Sablauer, MD, PhD; Brian Elrod


BrazilInstituto de Medicina Integral Professor Fernando Figueira (IMIP) and Centro de Hematologia e Oncologia Peditrica (CEHOPE) (Recife) Hospital de Clinicas and Hospital Pequeno Principe (Curitiba)Hospital de Cncer de Barretos (Barretos)

ChileHospital Luis Calvo Mackenna (Santiago)

ChinaShanghai Childrens Medical CenterBeijing Childrens Hospital

Costa Rica Hospital Nacional de Nios (San Jos)

EcuadorHospital de la Sociedad de Lucha Contra el Cncer Ncleo de Quito

El SalvadorHospital Benjamn Bloom (San Salvador)

GuatemalaUnidad Nacional de Oncologa Peditrica (Guatemala City)

HondurasHospital Escuela Materno Infantil (Tegucigalpa)

JordanKing Hussein Cancer Center (Amman)

LebanonAmerican University of Beirut/Childrens Cancer Center of Lebanon (Beirut)

MexicoHospital Peditrico de Sinaloa (Culiacn)Hospital Civil de Guadalajara Hospital General (Tijuana)

MoroccoHospital dEnfants (Rabat)Hospital 20 Aout 1953 (Casablanca)

PhilippinesSouthern Philippines Medical Center (Davao City)

VenezuelaHospital de Nios J.M. de los Ros (Caracas)Hospital de Especialidades Peditricas (Maracaibo)

20 PARTNER SITES IN 14 COUNTRIES


POEM: A NETWORK OF REGIONAL CENTERS IN THE MIDDLE EAST AND MEDITERRANEAN ADDRESSING DISPARITIES IN PEDIATRIC CANCER CARE AND TRAINING Our newest network is the Pediatric Oncology East and Mediterranean Group (POEM). Formed in 2013 as a cooperative network of regional physicians, scientists, and healthcare professionals, POEM has already started sharing experiences regionally and will ultimately serve as a platform for cooperative clinical trials and optimization of care for pediatric oncology patients. With an organizational structure similar to that of other cooperative groups and members with diverse skills and needs representing multiple countries, POEM is positioned to serve its members and address the disparities in care for children with cancer.

Under the leadership of Sima Jeha, MD (Oncology), the IOPs interface with POEM is multifold: IOP staff serve on the POEM Board of Directors and the Program provides financial support for meetings. The membership of POEM, with highly diverse backgrounds and great enthusiasm for this new cooperative network, has already crossed political and territorial boundaries to focus on the higher purpose of improving pediatric oncology research, training, patient care, and advocacy through multidisciplinary teamwork.

CONTINUED SUCCESS OF THE LATIN AMERICAN CENTER FOR NURSE EDUCATORS Quality pediatric oncology nursing care is an essential component to achieving successful patient outcomes. In high-income nations, newly hired nurses undergo extensive subspecialty education, training, and supervised clinical immersion prior to providing independent care. However in low- to middle-income nations, specialized pediatric oncology nursing education and training is not widely available. In addition, nursing-quality assessments conducted by IOP staff identified the need for subspecialty training of pediatric oncology nurses at several partner sites in Latin America. To provide specialized pediatric oncology nursing education and training in Latin America, Sara Day, PhD, RN, developed and implemented a new nursing education

model. The model consisted of pioneering the role of a full-time pediatric oncology nurse educator at Latin American partner sites. Hospital Luis Calvo Mackenna, our partner site in Santiago, Chile, took on the role of providing this nurse-educator training. The partnership between the IOP Nursing Program and the Division of Nursing at Hospital Luis Calvo Mackenna helped establish the Latin American Center for Pediatric Oncology Nursing Education, a regional center for pediatric oncology nursing education. This program continues to be successfully implemented by Courtney Hahn, CPNP.

The 4-week comprehensive nurse-educator training curriculum that was developed encompasses many components: (1) pediatric oncology nursing lectures; (2) direct observation of patient care with a preceptor; (3) self-learning activities (i.e., each student develops educational materials for the nursing staff at their hospital); (4) visits to support units (e.g., pharmacy, blood bank, psychosocial and nutrition units); (5) development of teaching/presentation skills; (6) quality improvements based on Joint Commission International standards; (7) chemotherapy courses; (8) central line courses; and (9) palliative care and pain management courses.

Once nurse educators return to their hospitals, they develop an orientation program for all newly hired nurses working on their pediatric oncology units. These programs are based on the one they completed at Hospital Luis Calvo Mackenna and adapted to their local situation. With ongoing support and mentoring from the IOP Nursing Program, this network of nurse educators is empowered to distribute its knowledge to ensure the safe delivery of pediatric oncology nursing care.

The pioneering efforts of the IOP Nursing Program to train pediatric oncology nurse educators in Mexico, Central America, and South America have proven to be a sustainable and effective approach to improv-ing the quality of care for patients at St. Jude partner sites. Nurse educators have a significant role in not only improving the quality of patient care but also advancing nursing knowledge, skills, and professionalism at IOP partner sites.


Sima Jeha, MD

Courtney Hahn, CPNP


CENTRALIZED TRAINING FOR PREVENTION AND CONTROL OF INFECTIOUS DISEASES Miguela A. Caniza, MD (Infectious Diseases), leads the infectious diseases group within the IOP. Her team is working toward increasing the quality of care at partner sites by standardizing procedures to prevent infections. A primary objective of the group is to bring all partner sites up to the current standards of practice in a step-wise fashion. For each of the participating sites, the IOP identifies, trains, and continuously mentors multidisciplinary teams comprising infectious diseases physicians, preventionists, and data managers. Team members then manage the care and prevention of infections at their pediatric cancer clinic. By providing knowledge, skills, and access to relevant and up-to-date information about infection care and prevention, the IOP can consistently raise the local standards. The trained team conducts surveillance of infections and their risk factors; systematically tracks staff compliance with infection prevention and control practices such as hand hygiene, vascular access, and collection of blood cultures; trains other hospital staff in essential infection prevention and control competencies; and reports infection prevention and control program performance indicators to their institutional leaders and the IOP.

Because health education and promotion is essential for building and sustaining an effective infection care and prevention program, the IOP has developed and administered highly efficient training of healthcare providers in infection care and prevention and data management. We collaborate with leading educational organizations and centers and health institutions in the United States (e.g., Centers for Disease Control and Prevention and the Association of Professionals in Infection Control and Epidemiology) and at international sites. As of 2013, 199 infection preventionists, physicians, and healthcare professionals had received training, which consisted of 10 weeks of online coursework and a 2-week practicum in Mexico City. In 2013 alone, trainees from 15 hospitals and six countries attended this course.

The infectious diseases group of the IOP has enabled the training of teams at pediatric cancer clinics in Guatemala, Honduras, El Salvador, Nicaragua, Mexico, Ecuador, Argentina, and the Philippines. Similar teams are being developed in Haiti, Morocco, and at additional sites in Honduras and Mexico. Improving hand hygiene, adopting procedures for safe vascular access, and developing methods to obtain high-quality blood

cultures are some of the topics included in the training. The benefits of this training at our partner sites and other regional hospitals cannot be overstated. Training is central to improving infection prevention and control; however, the development of organized infection control teams across regional partners has facilitated the study of issues common to many local sites. In the past year, we have published articles assessing infectious waste management policies and inpatient infections specifically associated with treating acute leukemia. Through these publications, valuable knowledge is further distributed by the IOP that will benefit future implementation of infection control training and approaches.

INTERNATIONAL VISITORS PROGRAM AT ST. JUDE PROVIDES SPECIALIZED TRAINING Under the direction of Ibrahim Qaddoumi, MD (Oncology), the International Visitors Program (IVP) within the IOP provides specific, specialized training at the St. Jude campus. International healthcare professionals are selected to visit St. Jude and fulfill a specific need for their partner institutions. The IVP provides an opportunity for visitors to observe the St. Jude model of medical care, which is based on patient care delivery by a multi-disciplinary team that treats children with cancer or other catastrophic diseases.

Since 2008, IVP participants have come to St. Jude from more than 67 countries. Our international visitors have had diverse backgrounds covering a wide array of specialties: physicians specializing in oncology, psychiatry, surgery, infectious diseases, and radiation oncology and healthcare professionals with training in nursing, psychology, social work, nutrition, pharmacology, dentistry, physical therapy, and medical laboratory technology.

Through the IVP, St. Jude directly educates IOP partners. The IVP was designed to provide international health-care professionals a brief exposure (2-6 weeks) to specific clinical programs at St. Jude. The IOP receives approximately 130 applications to the IVP per year and accepts 60 to 80 visitors annually; 50% of our visitors come from IOP partner sites. Although the experience of being at St. Jude is in itself rewarding to visitors, the real benefit is reaped when those visitors return home and teach their colleagues what they have learned.


Miguela A. Caniza, MD

Melanie Jackson; Beth Schaeffer; Ibrahim Qaddoumi, MD; Blaire Benavides


CONCLUSION

The IOP is addressing global pediatric cancer

care deficits in a scalable and sustainable

manner. By providing resources and training

to healthcare providers at international partner

sites and employing new approaches to more

effectively spread knowledge across those

regions, the IOP is working to eliminate health-

care deserts and improve patient care and

survival for all children with cancer or other

catastrophic diseases.


Heng Xu, PhD; Virginia Perez-Andreu, MD; Jun J. Yang, PhD


Hematologic malignancies encompass a spectrum of diseases

that arise due to uncontrolled synthesis of blood cells. Acute

lymphoblastic leukemia (ALL) is the most common form of

childhood cancer. Although the cure rate for children with this

disease is approximately 90%, there are subsets of patients

with high-risk ALL who continue to suffer poor prognoses.

Investigators in the Hematological Malignancies Program

and the St. Jude Childrens Research Hospital Washington

University Pediatric Cancer Genome Project are investigating

the genetic and epigenetic factors that cause the development

of ALL and drug resistance.

As a result of improved overall outcome, the population

of adult survivors of childhood ALL is increasing. Thus,

epidemiology and cancer control investigators are focused on

identifying long-term, treatment-related effects and working

with oncologists to modify treatment regimens to ensure the

best possible health and quality of life for survivors.

Unlike ALL, acute myeloid leukemia (AML) represents only

about 18% of pediatric leukemias diagnosed each year. The

cure rate of AML is about 70%, which is also lower than that

of ALL. AML is a much more heterogenous disease and is

often resistant to contemporary treatments. The rate of relapse

and refractory disease also remains quite high. Thus, St. Jude

investigators are designing new targeted therapies and

exploring cutting-edge approaches, such as immunotherapy,

to improve the outcome of patients with this catastrophic disease.

TOWARD IMPROVING TREATMENT AND SURVIVORSHIP OF CHILDHOOD ACUTE LEUKEMIAS


GENOMIC ANALYSES OF AND INHERITED PREDISPOSITION TO ACUTE LYMPHOBLASTIC LEUKEMIA The natural history and cause of ALL are largely unknown. It has been hypothesized that interindividual genetic variation is associated with disease susceptibility. Although certain congenital genetic abnormalities (e.g., Down syndrome) are associated with a high risk of developing ALL, little is known about the genetic factors predisposing the vast majority of children to ALL. Inherited genetic risk factors for cancer can be divided into two main classes: rare mutations that are seen in families with malignancies occurring in multiple generations and that confer high risk (e.g., BRCA1 and BRCA2 in breast cancer) and common variations that are seen in the general population and are associated with modestly increased risk of certain cancers.


MAPPING THE GENOMIC LANDSCAPE OF CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA Specific genetic alterations have been identified in ALL and are associated with various aspects of the disease such as its development (leukemogenesis) and response to treatment. However, the genetic bases of many ALL subtypes remain poorly understood. Therefore, cutting-edge genomic analyses are warranted to increase our knowledge of and discover new approaches to curing all subtypes of the disease.

Charles G. Mullighan, MBBS(Hons), MSc, MD (Pathology, Oncology), and colleagues have identified genetic mutations that cause rare familial ALL. In the first of two Nature Genetics articles, the researchers reported the genomic profiles of 124 children with hypodiploid ALL. The term hypodiploidy indicates that the leukemic blasts contain fewer than the normal 46 diploid chro-mosomes found in human cells. Hypodiploid ALL is a severe and poorly understood subtype of ALL because of its rarity; children and adults with this disease experi-ence extremely poor outcomes.

Whole-genome and -exome sequencing of tumor DNA and matched remission DNA showed that 91% of children with low-hypodiploid ALL (containing 32-39 chromosomes) carry mutations in the TP53 gene. TP53 encodes a tumor-suppressor protein that, among other functions, mediates DNA repair and apoptosis. The TP53 alteration was detected not only in the nontumor DNA from nearly half of the cases but also in parental DNA in several cases studied, indicating that it is an inherited mutation. In contrast, low-hypodiploid ALL in adults was not associated with germline TP53 mutation. Dr. Mullighans team concluded that childhood low-hypodiploid ALL is most likely a manifestation of the Li-Fraumeni syndrome, a rare autosomal-dominant familial cancer syndrome that is generally characterized by a range of solid tumors and brain tumors.

Charles G. Mullighan, MBBS(Hons), MSc, MD; James R. Downing, MD


PAX5 MUTATION CONFERS SUSCEPTIBILITY TO PRE-B CELL ACUTE LYMPHOBLASTIC LEUKEMIA Pre-B cell ALL (B-ALL) is the most common pediatric leukemia, accounting for 85% to 88% of the cases of pediatric ALL. The siblings of children with B-ALL have as much as a 4-fold greater risk of the disease than do children in the general population, and occasionally childhood ALL is inherited as a mendelian disorder.

In their second Nature Genetics article, Dr. Mullighan and colleagues investigated inherited mutations in PAX5, a gene that encodes transcription factors that maintain the identity of mature B cells. PAX5 mutations were detected in two unrelated families: one family was of Puerto Rican ancestry, and the other was of African American ancestry. In each family, B-ALL developed in five members. The mutation encoded a glycine-to-serine substitution at residue 183 (p.G183S), thereby

causing the partial loss of PAX5 activity. This variant had not been previously reported in any cancer database or in the ALL literature. In both families, the p.G183S variant segregated with B-ALL in all members affected by the disease. In addition, several members of both families who were not affected by leukemia carried the variant, indicating that the penetrance of the mutation was not complete. Ongoing cancer-sequencing analyses and whole-genome association studies will most likely reveal other inherited mutations that substantially affect not only children with ALL but also their family members. To meet the need of those with such mutations, St. Jude has established a new Division of Hereditary Cancer Predisposition in the Department of Oncology to provide much-needed genetic counseling, monitoring, and inter-vention for families dealing with inherited susceptibility to leukemia.

Figure. Recurring mutations in 124 children with hypodiploid ALL. The cohort was subdivided into near-haploid (24-31 chromosomes), low-hypodipoid (32-39 chromosomes), and near-diploid (40-43 chromosomes) groups. Abbreviations: GEP, gene-expression profiling; Ind, induction treatment failure; indel, insertion-deletion mutation; NA, not available; NGS, next-generation sequencing; NS, not significant; SNV, single-nucleotide variation; SV, structural variation; TRG, rearrangement of the T-cell receptor gamma locus; WES, whole-exome sequencing; WGS, whole-genome sequencing. 2013 Holmfelt L et al


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