RESEARCH

XMRV Q & A at the CFSAC with Dr. Coffin and Dr. Peterson (Oct 09)

(Transcribed by Garcia, Ed remarks are by Cort Johnson)

The talks were great but we really got into the nitty-gritty when the federal advisory panel got into the act. Dr. Coffin, a top retrovirologist and Dr. Peterson gave substantive answers to all the committee members questions. (Watch out for Dr. Glaser's long 'question' early on. 

Arthur Hartz: What was found was not only an association between this virus and CFS but an incredibly strong association. Are there any reasonable alternative explanations for an association that strong other than a cause-and-effect, and in particular is it possible the association could go the other way, that somehow people with CFS could be more susceptible?

Dr Coffin: I think it’s still a possibility. I agree with you the striking correlation is certainly strong evidence pointing in the direction of cause-and-effect, but it’s not conclusive and that’s the only point I want to make.

Arthur Hartz: What would be a possible way that could have happened other than cause-and-effect, to be that strong?

Dr Coffin: Well there are a couple of possibilities. The patients that were looked at as far as I understand came from a few defined areas. There might be coincidentally an outbreak of infection in these various specifically defined areas. Just coincidence. That seems improbable to me, I have to grant you that. But it could be that patients are much more susceptible to infection with something that is widespread in the environment but most people escape getting infected unless you suffer from the kinds of immunodeficiencies that are associated with this disease. And that could lead to this kind of association.

 If in fact it’s a very common virus in the environment but that very, very few people get infected because they can mount an immune response and if there is some big hole in the immune response of these people the defects in the NK-cells was mentioned. And that in fact was the hypothesis that the group in Cleveland set out originally to test with the prostate Cancer because they found this RNASE-L mutation was associated with increased incidence of prostate cancer. They hypothesized that this mutation would make these patients more susceptible to a virus, and then this virus might or might not cause the disease actually but that they might find an associated virus and based on that line of reasoning they went to look for viruses.

So it’s not an unreasonable thing although I will grant you I think that given what we are looking at today in terms of data, I think that’s less likely. And the final possibility is that everybody is infected, but that it’s much, much easier to detect in patients who have this disease.

Ronald Glaser: I’m an old tumor hunter, I mean an old virus hunter, I’m an EBV guy and I’ve been working off and on with CFS sort of as a hobby for about 20 years. One of the things I tell my trainees as we start thinking about things that are easy to deal with in the laboratory or easy to deal with in the clinic that we know about that what attracts me to work in this area is the possibility that it allows me to think about EBV-related disease in a completely different way. And I say that because after 20 years how come we haven’t proven that EBV or HHV6 or CMV or the other viruses that have been associated with CFS - you know why aren’t we coming up with answers? To me, hello, nothing is easy and if we are dealing with things we’ve never thought about before, about virus replication and how viral proteins independent of what the virus is doing have their own role in pathophysiology in these diseases, these put us in a very different kind of a ball-game in trying to figure these out.

(Ed - Dr. Glaser has been working on and off for many years on the theory that a smoldering herpesvirus infection is producing proteins that are evoking an immune response, which, in turn, is causing the symptoms of chronic fatigue syndrome. )

Glaser - So as this work goes forward you’re going to have to take into account what’s now known about CMV, EBV, HHV6, and the Tufts herpes and the Tufts retroviruses that are out there because there’s good data, there’s good studies showing relationships between those viruses and CFS. How do you sort all that stuff out?

So could one answer be that there’s, first of all we agree that there’s a heterogeneous population out there, that makes it very difficult for people like me to link one virus to a population like that. Because there is so much unknowns in that population that either that we know about or we don’t know about to control for.

What about the possibility that one or more of these viruses are required for CFS? Do they interact with each other? Does the Tufts virus or this virus reactivate or stimulate the activation of other latent viruses and is that required? It only happens in some people so even though everybody’s carrying around latent EBV, unless they see this virus or vice-versa nothing happens.

These [new] studies are going to have to take into account those previous studies. Those other studies that have shown for example that acyclovir (or varieties of acyclovir) can make some patients with CFS feel better. Well to me that connection is EBV.  Ronald Glasser

And is genetics a background in all this? Polymorphisms for cytokines and how they react when these viruses are synthesizing their proteins, and their proteins are inducing for example pro-inflammatory cytokines. It’s pretty complex stuff, but the point is these [new] studies are going to have to take into account those previous studies. Those other studies that have shown for example that acyclovir (or varieties of acyclovir) can make some patients with CFS feel better. Well to me that connection is EBV. Those people may have EBV so that’s why they’re reacting to acyclovir and that’s why they’re feeling better. These things have to be taken into account because those drugs are related to the ability to block EBV DNA replication and therefore virus replication. Not a retrovirus, but you can’t ignore these, these things have to be put in context. So that’s one thing.

Dr Coffin: I just want to make an analogy. Lots of patients with HIV feel better when they’re given anti-herpes virus drugs or anti-pneumocystis drugs or anti-other drugs. The critical issue is: what is the real trigger for this disease? It may well be that herpes viruses, EBV and so on, are intimately involved in the pathophysiology of the disease, but are not necessarily causal to the disease, but are important as opportunistic infections as in the case of HIV. Hardly anybody dies of HIV infection, they die of opportunistic infections, cancers and things like that which are caused by the viruses. I think one has to start in a sense at a simple level, try to establish the role of this one specific agent and then work up to exactly the sort of pathophysiological issues that you’re getting into.

The critical issue is: what is the real trigger for this disease? It may well be that herpes viruses, EBV and so on... are not necessarily causal to the disease, but are important as opportunistic infections...Hardly anybody dies of HIV infection, they die of opportunistic infections, cancers and things like that which are caused by the viruses. Dr. Coffin

Ronald Glaser: Well one of the things I was going to suggest to get at that is follow up on the comment you made about the reagents. Sharing the reagents from lab to lab, so that you can make direct comparisons in these outcome studies. But what I would suggest that people do to deal with the complicated issue of these other viruses for whatever reason is to take the same serum samples or plasma samples that you’re going to be doing these retrovirus studies on and also do simultaneously some other studies related to EBV and HHV6 to account for that in the same serum samples that you’re doing the retrovirus. Maybe you’ll be lucky and be able to sort out what’s going on between these different groups of viruses.  

Leonard Jason: For Dan, is it possible as Ron is suggesting that this retrovirus is kicking up different other viruses and that potentially the reason we’ve got so much diversity in the samples is that for some people you’ve got certain viruses being kicked up, for others you’ve got other ones and that this mix potentially is being activated by some types of retroviruses that this might be the thing that starts it?

And in fact Dr Coffin I just wanted to ask a related question, when you kind of talked about the European sample [German prostate study] not finding this retrovirus and very different results, could you just help us understand as an expert in the field when you mention “well-validated assays” where are the things that can go wrong in different laboratories if they’re not careful such that they could end up with maybe even comparable samples and finding completely different results? What are the things we need to be careful about and what types of standards do we need to have to make sure the science is at the top level?

Dr Coffin: The immunological assays are in many ways the most problematic because you’re using the ability of the patients to (produce), in the simplest case, you’re looking for antibodies in the patient against some standard virus. Well,a different patients with different conditions and different genetic backgrounds can make lots of antibodies that may cross-react with the agent that you’re interested in looking at, particularly for example against carbohydrates on surface proteins. If you have that kind of antibody in a patient that would give rise to a false positive.

Or there are lots and lots of things that people could have been infected with which would raise an immune response in someone which might by chance have some sequences which occur by cross-reaction. This is probably what happens in HIV tests. In the HIV Elisa test for example (which is the standard screening test) it’s substantially less than 100% specific and  is why a positive result there, still, after 25 years of using these assays,  has to be confirmed with a second test before its accepted as being positive. So that’s one kind of issue. It’s this kind of cross-reactivity.

 It’s our operating model that there’s a mingling of co-infections...My feeling is there have to be cofactors. Dr. Peterson

 Nucleic-acid based tests, PCR, as Dr Peterson showed can be much more reliable in that, but there are other issues with those tests too. For example how sensitive are they? In the case of a virus infection in blood, how many of the cells need to be infected with the virus before you can see it with this test? And these (tests) can also be messed up by unexpected genetic variation in the virus in the area you are looking at. You can miss viruses that are infecting because they don’t happen to be exactly the same sequence as what you need them to be to react with the primers that are used in these assays. So there are lots of things that can go wrong with these in terms of sensitivity and specificity of the test and this all needs to be really worked out.

(Ed. Among the things to be worked out - Could patients be producing antibodies to another similar virus which are being misinterpreted as the XMRV virus? Are researchers looking at the right genetic sequence for XMRV? Could they the infected with another virus that has a similar genetic sequence? Remember XMRV is identified by finding small bits of genetic sequences that are associated with it.  These are the types of things that have produced false positives in the past. Eliminating them as possibilities is standard procedure in the viral field)

Dr Peterson: I totally agree with that model and I think it’s our operating model that there’s a mingling of co-infections. What I’ve learned about this however is you’re just magnifying the complexity in trying to sort that out. It would make perfect sense now why some people have this herpes virus reactivated or another one or a combination. So I’m totally onboard with that. I have some other questions. For example, can this type of retrovirus integrate in a herpes virus?

Dr Coffin: There actually are examples of gamma-retroviruses integrating into herpes viruses. A virus called Merrick’s disease which is a commercially important virus of poultry and if you go look at these viruses you’ll find the remanence of retroviruses that have dropped themselves into the herpes virus DNA so that can happen.

Nancy Klimas: I think another point that’s actually Ron’s forte is that virus bits can do things and you were talking about the LTR having a profound oncogenic activation component. If you had a very low level but active infection without a lot of replication you might suggest from the genealogy here could you still have a fair amount of viral product being produced from a cell?

(Ed. Could the virus be sitting in cells without replicating but still producing a product that could eventually lead to cancer?)

Dr Coffin:  It’s a possibility, yes. Even if the virus is not replicating, it could be expressed at a fairly high level under certain kinds of circumstances. It might not be spreading from cell to cell because all the cells are already infected for example, so you can’t get it spreading along any further. Or you could conceivably have defective viruses getting in. There are models in the mouse where this kind of thing can be shown to happen.

Nancy Klimas: In CFS about 70% of the t-cells are activated which is very, very high and that’s probably being driven by polycolonal antigens out there like EBV or other things. So you have a system that’s driven, it’s turned on and then you have the viral baggage in the cell. It’s a low level virus but the cells movement could it be driving ...

(Ed. Dr. Klimas brings up the intriguing possibility that Epstein-Barr virus infection is turning on T-cells. When T-cells are activated  they rev up their metabolism greatly - perhaps  also increasing the metabolism of any viruses they are infected with - and increasing the amount of potentially damaging proteins the virus is producing.)

Dr Coffin: There could be enough antigen expressed on cell’s surfaces in order to drive a substantial t-cell response. It’s not hard to visualize that that is a possibility, just all (that) needs to be shown of course.  

Arthur Hartz: Would you say you have ruled out a single infectious agent as a cause of CFS? You’re not saying that this is likely at all to be the cause of CFS by itself because that would not fit the epidemiology that we know about the disease? Or do you still consider that a possibility that the XMRV could be the single infectious agent of causing?

Dr Peterson:  My feeling is there have to be cofactors. That has been bought up already, that needs to be determined.

Dr Coffin: Back in June when we first began to just hear rumors really of these studies that were coming out, one of the prostate cancer studies was presented in May and then this other was sort of beginning to bubble-up a little bit but the papers were still under review at the time as it turned out and so on but the first thing we did, putting on my NCI hat for the moment, was to organize a meeting which unfortunately couldn’t be published due to the nature of the unpublished data. We brought everybody that we knew of that was working in the XMRV area or might even just be interested in it together for a small meeting in NCI to discuss exactly these issues to try to make sure that we did not go down the road that had been gone down with HIV, as you say considerably to the detriment to the goal of the overall research effort.

We have to validate the clinical group that we are looking at and I can’t make that (point) strongly enough especially in publishing validity studies. If I don’t understand what patients they were looking at it will really mean little to me as a clinician. Dr. Peterson

Lucinda Bateman: I’ I’d just like to hear your insight about the difference between the patients your group looked at: well defined, very ill patients with cognitive dysfunction, immune abnormalities. How this group of patients might compare to a broad group of patients selected by the 1994 case definition, perhaps compared to the Wichita study? This may be unanswerable but I think it’s important for us to keep in mind these differences in the way we select patients.

Dr Peterson: I’m not going to speculate as to what the findings would be, but I would [say], along with validated assays we have to validate the clinical group that we are looking at and I can’t make that strongly enough especially in publishing validity studies. If I don’t understand what patients they were looking at it will really mean little to me as a clinician.

(Ed. Dr. Bateman brings up the important point that the original study group consisted of very ill patients with specific immune and other abnormalities. WIll the XMRV results translate to a perhaps more typical ME/CFS patient? Dr. Mikovits has said that based on unpublished work that the results will translate to most patients.  Dr. Peterson was not willing to speculate on that; the most important thing for him at him at this point is that replication studies use the same type of patients; ie patients with very low VO2 max levels during exercise and RNase L, natural killer cell and cytokine abnormalities. Dr. Peterson has focused on this type of patient for the past 20 years or so.thus

Leonard Jason: Just as a follow up question, that’s a really interesting meeting that you had at NCI and I just wanted to ask some follow-up questions about that meeting. Were there any discussion about transmission issues, blood bank issues at that meeting, and also since you are trying to standardize procedures which sounds like you are trying to avoid some of the problems that occurred 20 years ago was the CDC involved in any of those discussions, and if not why not? And finally just last issue of patient selection, are you concerned at all about the identification of patients and some of the potential problems with that for this area?

Dr Coffin: I’ll’ll just answer the last first. I completely agree with Dr Peterson that validating assays with a very well defined set of samples from a well defined set of patients, where you know everything you really need to know about them and then using that as a benchmark for the quality of your assay sensitivity, specificity and so on, also well defined sets of controls I might point out, is really critical to being able to do these studies in a meaningful way.

Regarding the meeting, we had one representative from the CDC, the meeting was only about 20, 25 people, there was somebody from the CDC present, a scientist who had a research-interest in this area. There was a scientist from FDA present and lots of people from both the outside research community, Dr Mikovits was there for example, Dr Singh who did the prostate cancer work, Dr Silverman. So you know the people we could identify as being the big guns if you like in this field at the moment, along with a number of intramural scientists who were very interested in helping out with this problem and turning over their particular research expertise and we did discuss issues like blood supply, like protection of lab workers and things like that.

We came to the conclusion that these were issues that needed to be addressed. We did not come to any conclusions regarding recommendations or anything else except for making sure that they were high on the agenda of issues that needed to be addressed. And that was really the goal of this meeting to set an agenda for research going forward, and to develop the kinds of collaborative relationships that we thought were strongly needed.

Morris Papernik: Thanks again for the great discussion. If the XMRV and prostate association had been known since at least 2005, had there been any prospective trials looking at the possibility of XMRV association in the blood supply as Eleanor had alluded to before and if that had been done since 2005 wouldn’t there [by now] be a significant amount of information than we already know of the general population with XMRV?

 Dr. Coffin: But once that came to light I think there was considerable excitement within the virological community, particularly among retrovirologists I know. I’ve had many people come up to me and say “How can I get involved?

Dr Coffin: To answer the second question, yes there might well be. As far as I know no such studies were done on this virus during that time. Other studies were done but they are mostly virological studies establishing the nature and the biological properties of the virus and so on.

Morris Papernik: So would we turn to the blood banks for that information?

Dr Coffin: Yo You can ask them. At that time the thinking was that it was a few patients, a few cells. There was no epidemic of prostate cancer which would suggest it as an infectious disease I think. And it didn’t perhaps set off a large a red-flag as it probably should have actually at the time, to be honest with you. There was concern for example about the issue that I raised that it wasn’t completely established, as it is quite well now, that this virus was not some kind of an artifact and I think that all really didn’t develop in a way that would raise a big flag until just the last few months.

Eleanor Hanna: That’s what I’m trying to explain about the reds study. Something has to present as a possibility as danger to the blood supply and that’s when they determine the prevalence in these smaller studies and if it does look as though it could be a problem then it’s taken over and handled at the federal level very carefully. So in terms of the cancer stuff there were a number of studies done and that’s when the blood people gave me a number of papers, the transfusion studies from Scandinavia and so on, huge samples and they weren’t worried about the cancer and transfusion, especially with prostate cancer.

Morris Papernik: And now the newer study, the German study suggests that maybe it might not be that strong of a connection.

Eleanor Hanna: Right. So I think the real issue for us is the relationship with CFS and what does that mean.

James Oleske: I: It’s very clear to me that we don’t want to have another “Band Plays On” scenario, and I think the blood community is very sensitive to that and so let’s hope and in fact maybe this committee can recommend that based on what we’ve heard today there needs to be a definitive work on the safety of the blood supply.

Eleanor Hanna: As I said, they told me that Dr Venkl Bush at the blood systems research institute is studying the supply now and they will act on what he finds

Christopher Snell: I wI wonder if you could comment on your thoughts on whether the association of this retrovirus with CFS has really held back any advances that we might have made and whether there is potential for that to happen in the future and if so how do we guard against that?

Dr Coffin: I don’t completely understand you, you mean because of the disease itself?

Christopher Snell: Because of the image the disease has.

Dr Coffin: Yeah. Of course. That’s not my sense. In terms of what’s happened since the virus. Before that, it’s hard to work on something when you don’t really see something to work on. If you’re a retrovirologist you certainly, unless you have the insight that Dr Peterson and Dr Mikovits had, you wouldn’t necessarily have gone after that . But once that came to light I think there was considerable excitement within the virological community, particularly among retrovirologists I I know. I’ve had many people come up to me and say “How can I get involved? What can I do from my particular perspective?” [To Dr Peterson] You’ve probably heard the same kinds of things?

Dr Peterson: Yes, absolutely.

 But once that came to light I think there was considerable excitement within the virological community, particularly among retrovirologists I know. I’ve had many people come up to me and say “How can I get involved? Dr. Coffin

Dr Coffin: I I don’t think there’s any prejudice against working on this virus because of the disease. I mean this is a disease which affects a minimum, I suppose, of a million people and it’s as many people as are infected by HIV and there may be many, many more infected with this virus than are infected with HIV. Everybody recognizes this is potentially extraordinary importance and everybody wants a piece of the action in a sense. I mean scientists like to discover things and it looks like there is fertile ground for discovery here.

Nancy Klimas: In response to you Chris, Bogita Evangard who is a very fine infectious disease doctor, colleague in the CFS community said her colleagues are coming out of the woodwork wanting to work with her now, she feels validated she feels, the very people that were interfering with her promotions and so on because of this disrespected area that she had been working with are now begging her for samples. So it’s very interesting that that came to be.

Dr Coffin, it’s very important particularly since we are being broadcast in a webinar that to try to put a timeline together that’s realistic for patients. I already know of people on anti-retrovirals without even a blood test and I’m very, very concerned that some very bad decisions are going to be made over the next few months. It’s hard to state timelines like that.

Nancy Klimas: I, I know but just to have an accurate test?

Dr Coffin: It’s very hard to predict how the course. I would hope, I still have an image of “the band played on” of the secretary of HHS and a prominent scientist getting a standing up and promising a vaccine in a couple of years, and an image that just doesn’t go away. I want to be very, very careful about a timeline. But I would think it not unreasonable to imagine that we could have a test in 6 months and I hope sooner. That, or a battery of tests which could be used and have them validated and sort of accepted by the scientific community as it were, and had begun then to do analyses on stored samples principally at first.

 But once that came to light I think there was considerable excitement within the virological community, particularly among retrovirologists I know. I’ve had many people come up to me and say “How can I get involved? Ed - The Whittemore Peterson Institute's test is a test that they've internally validated. Dr. Coffin is talking about a test that the scientific community agrees is the best test for XMRV. Several different laboratories in different research institutions and elsewhere will be coming up with their own test; overtime, hopefully, one test will stand outt and that will be the test that researchers, at least, will rely on.)

But I imagine there will be retrospective studies. There are many, many collections of stored studies we have plans to look at some that were collected for Aids in our research over the years for example. And other groups have their own collections of things, and so once we have these tests and I think 6 months is not unreasonable but I don’t want to make any promises. We should be able to be doing that and hopefully we’ll have some results from all of that in a year or so.

Nancy Klimas: - You’ve moved on then to drug development, are there laboratory models, in-vitro models that might help?

Dr Coffin: Well now we need to know something about patpathogensis to understand whether that works. I mean one way to learn about the pathogenesis as we’ve learned from HIV is in a controlled trial situation, not you know borrowing your friend’s drugs or something like that. We know there are some antivirals that work against XMRV in the laboratory. That’s been done, there was a presentation at the same meeting in May about that. Actually you may not know that AZT was first discovered by Burrows-Welcome using the closely related Murine Leukemia Virus as a model. That was the means of discovery. There are already retroviralspan> th that work against this, so that those could be used in a trial, not necessarily a treatment trial but a trial just to see what the pathogenic mechanisms of the virus is.

Leonard Jason: I just want to say that this has been a fascinating panel discussion, and I just welcome our ability to really process these ideas. This is wonderful. A quick question for John [Coffin] and then Dan [Peterson]. You’ve been around John you know for decades ,as you said, in this retroviral world and I‘m just kind of wondering given your experience and history, and seeing other retroviruses now, do you have a sense of the resources that might be needed at the federal level or other levels that this data that you’re looking at might require and whether those resources are available and if they’re not available how might this particular advisory committee make recommendations so that they become available?

 We know there are some antivirals that work against XMRV in the laboratory....Actually you may not know that AZT was first discovered by Burrows-Welcome using the closely related Murine Leukemia Virus as a model..Dr Coffin

Dr Coffin: The first question depends on the timeframe. Over the short term of course the resources come from re-direction of things that are on-going. Many scientists have on-going research projects that are fascinating and wonderful but not necessarily directly pointed at any specific issue and they have the ability to, not on a dime often, because it’s really quite disruptive to a lab to all of a sudden start working on something else, as those of you who run labs know. You know you take a postdoc who’s in the middle of some project that’s eventually going to give him a job and suddenly tell him to do something else. You got to be very careful about doing those kinds of things because they can be quite disruptive to people’s careers. But that said many labs, mine included have the ability to devote a fraction of our work to these issues, and over the short term that’s how you get things going.

In In addition to that there are also pockets of money here and there at NIH which people compete for but can be tapped for this kind of thing, if there is enough excitement associated with it you can competitively go in so there are mechanisms at NIH for getting funds, not huge funds I’m not talking mega-millions, but getting funds that will support 1 or 2 people in a lab and so on to work on projects that become particularly time consuming and hot. And that’s the way you get things going to begin with.

And then over the longer term you have to get some specific funding mechanism in place. NIH has a certain amount of funding this was mentioned they can devote to our phase where a pot of money is initially set aside for grants on a specific topic. They are reviewed all separately as a group and are paid until the money runs out basically. And again the program officers compete intramurally for these for some larger pool of money which then goes into these. And then over the longer term one probably wants to talk about getting money dropped in appropriately either new money coming from Congress, or diverted money, you know a more long term allocation of resources.

  I think historically there has been no collaboration, particularly with the CDC. Dr. Peterson

Leonard Jason: And for Dan I just want to follow up on a question that I sort of asked several times. We’re constantly talking about the need for well validated assays, measures, collaboration and this is just, its coming out again and again through our discussions, and I’m just wondering if you’re willing to talk at all about how you feel about the potential collaborations with important agencies like the CDC, what has happened, and what you think might happen in the future?

Dr Peterson: I think historically there has been no collaboration, particularly with the CDC. I would hope and incidentally Ampligen is certainly not on the fast track since it’s been in the pipeline for 20 years which certainly couldn’t be considered fast track. Which is another example of lack of collaboration with respect to these issues.

I think this is of such magnitude that collaboration almost understates it. This is a project that must be done by people with resources such as the NIH, and CDC etc. The seed that was planted here through private enterprise collaborating with one of the agencies, the NCI and the Cleveland clinic accomplished a great deal. But that must be taken levels above that and actually shown priority. And that’s what I hope will occur.

Thanks again to Garcia for his trifecta; transcribing this Q&A and both Dr. Coffin's and Dr. Peterson's testimony at the CFSAC.