by Zheng-Shan Chong, Shweta Jadhav, and Shainan Hora
As governments and healthcare workers across the world race to contain the spread of a newly discovered coronavirus, scientists in Singapore have not been idle.
The virus, which causes an acute respiratory disease called COVID-19, has infected more than 129,000 people and claimed over 4,700 lives worldwide. In the past two weeks, a surge in COVID-19 cases across the Middle East, Europe, and North America led to the World Health Organisation to declare the disease a pandemic on the 12th of March, 2020.
As of the end of March, Singapore has reported a total of 879 confirmed cases, the majority of which were locally transmitted. For now, community transmission is thought to be largely contained within localised clusters, but an uptick in imported cases in the past few weeks have highlighted how Singapore’s status as an international travel and business hub makes us vulnerable to reinfection from overseas. Therefore, as more COVID-19 cases spring up across the world, there is a pressing need to improve our abilities to diagnose, treat and prevent the spread of the virus. On this front, scientists from local research institutions and biotech firms have been instrumental in supporting Singapore’s response to the outbreak.
Scaling up diagnostic capabilities with high throughput detection kits
Even before the rise in locally transmitted cases, pre-packaged test kits were already being developed in Singapore and are now used in hospitals here for diagnosis, with capacity to scale up production for local and international distribution. This is in sharp contrast to the 2003 outbreak of Severe Acute Respiratory Syndrome or SARS, where such diagnostic kits were not available until more than a month into the outbreak. The diagnostic kit, Fortitude 2.0, detects the presence of SARS-CoV-2, the virus that causes COVID-19, in patient samples by amplifying unique regions of the viral genome.
Dr Sidney Yee, CEO of the Diagnostics Development Hub (DxD Hub) which facilitated the development of the diagnostic kit, credits long-standing partnerships between researchers and clinicians for its timely development. The same teams from the Agency for Science, Technology and Research (A*STAR) and Tan Tock Seng Hospital (TTSH) have previously collaborated to produce diagnostic kits for the H5N1 bird flu and Zika virus.
DxD Hub’s established capabilities for turning laboratory prototypes into products ready for clinical use, coupled with the proper regulatory guidance, fast-tracked the development, production and distribution of this diagnostic kit. Fortitude 2.0 is a one-step RT-PCR test that can multiplex up to 96 samples in one run to turn around results from extracted RNA in 1.5 hours. It detects down to 25 copies of virus per reaction, with no cross-reactivity with other respiratory viruses. The kit has been given provisional authorisation by the Health Sciences Authority (HSA) for its intended use in Singapore and in the process of being licensed non-exclusively to multiple local start-ups for commercial production and distribution. It has already been licensed to MiRXES.
Dr Sidney Yee, CEO of the Diagnostics Development Hub (DxD Hub), credits long-standing partnerships between researchers and clinicians for its timely development. The same teams from the Agency for Science, Technology and Research (A*STAR) and Tan Tock Seng Hospital (TTSH) have previously collaborated to produce diagnostic kits for the H5N1 bird flu and Zika virus.
At least three other Singapore-based biotech companies have also announced the development of SARS-CoV-2 testing kits capable of rapid, high-throughput detection. In late January/early February, Veredus Laboratories and Acumen Research Laboratories announced similar diagnostic kits based on the amplification of unique viral sequences, which promised to shorten the time needed for a diagnosis from one day (at that time) to two hours by reducing the need for additional sequencing. In mid-February, Vela Diagnostics announced the development of a SARS-CoV-2 diagnostic assay – ViroKey™ SARS-CoV-2 RT-PCR Test – configured to work on their proprietary automated workflow system to process up to 48 samples in 3.54 hours in a single run. The kit uses a dual target approach to increase specificity and sensitivity, and does not cross-react with pathogens that cause similar symptoms, such as influenza, says Sam Dajani, interim CEO and Chairman of Vela Diagnostics. To facilitate easy adoption of the assay by laboratories, a manual workflow option is also available. More recently, JN Medsys has also announced the production of a SARS-CoV-2 RT-PCR diagnostic test kit, ProTect Covid-19 kit, which received HSA approval for in-vitro diagnostic use on the 19th of March. JN Medsys is a home-grown biotech company led by Dr Johnson Ng specializing in digital PCR systems and consumables.
Whilst the amplification reactions of the diagnostic kits developed by A*STAR, Acumen Research Laboratories and Vela Diagnostics are run on standard thermal cyclers, Veredus Laboratories’ VereCoV™ detection kit integrates amplification and detection on a single chip by combining thermal cycling chambers and a microarray for hybridization of the amplified sequences to pre-loaded DNA probes. Each detection kit contains 50 chips, with each chip being used to amplify a single patient sample. The chips are run on Veredus Laboratories’ proprietary VerePLEX™ Biosystem, which can multiplex the screening and detection of up to 25 patient samples in under 2.5 hours. Each chip can detect as few as 100 copies of viral RNA and boasts 100% reproducibility, says Dr Damian Foo, Senior Manager of Supply Chain and Product Manager at Veredus Laboratories. The VereCoV™ Detection Kit has received authorisation for clinical use by the HSA and is being used to test swab samples collected at land, air and sea checkpoints islandwide.
However, it is not the only chip-based coronavirus detection system in Singapore. Dr Shao Huilin’s team from the Institute for Health Innovation and Technology (iHealthtech) at NUS is working to adapt their microfluidic enVision platform to detect genetic material from SARS-CoV-2. This chip relies on carefully engineered DNA-enzyme complexes to identify the presence of viral sequences in patient samples and triggers a colour change after 30 minutes depending on whether the sample comes from an infected person or a normal individual. It was originally developed to be a low-cost, point-of-care device meant to circumvent the need for sending samples to a specialised lab for processing. This would potentially allow for decentralised screening, for instance at GP clinics, enabling wider access to COVID-19 testing. Currently designed to detect the cancer-causing human papillomavirus, the team hopes to be able to adapt their chip to detect SARS-CoV-2 within the next few months.
Veredus Laboratories’ VereCoV™ Detection Kit has received authorisation for clinical use by the HSA and is being used to test swab samples collected at land, air and sea checkpoints islandwide, whilst Vela Diagnostics is seeking Emergency Use Authorisation from the FDA for their diagnostic assay. ‘We are also responding to enquiries from South East Asia, including Vietnam and Thailand, as well as Africa and the Middle East.’ says Mr Dajani, interim CEO and Chairman of Vela Diagnostics.
Beyond meeting local demand, biotech companies here also have their eyes set on the global market. MiRXES reportedly has the capacity to increase its production levels from 100,000 tests a week to 250,000 a week to supply regional demand if required, whilst Vela Diagnostics is seeking Emergency Use Authorisation from the FDA for their diagnostic assay performed on the manual workflow, which could cut time to clinical use in the US by at least 9 months. ‘We are also responding to enquiries from South East Asia, including Vietnam and Thailand, as well as Africa and the Middle East.’ says Mr Dajani.
Vaccine efforts underway after researchers successfully grow virus in the lab
Separately, researchers at Duke-NUS were able to isolate live SARS-CoV-2 virus from patient samples, as well as culture and verify its identity by next-generation sequencing, making Singapore the third country in the world after China to be able to grow the virus in the lab. This represents a big step forward for researchers as the live virus can then be used for infection studies in animals to test candidate vaccines or antiviral drugs.
In addition, being able to culture SARS-CoV-2 viruses has also enabled the development of a serology test capable of detecting virus-neutralising antibodies in individuals who have already recovered from an infection. This test was used to ascertain the missing link between two local transmission clusters, an application that was the first of its kind in the world. Neutralising antibodies in the blood are formed during an immune response and prevent the virus they target from continuing to infect cells. These antibodies typically remain in the blood for some time after the infection is resolved. Therefore, someone who has recovered from COVID-19 may not test positive on nucleic acid based tests, which surveys the amount of viral genetic material present in sputum or bronchial secretions, but would test positive on a serology test for antibodies against the virus.
Being able to culture SARS-CoV-2 viruses has also enabled the development of a serology test capable of detecting virus-neutralising antibodies in individuals who have already recovered from an infection. This test was used to ascertain the missing link between two local transmission clusters, an application that was the first of its kind in the world.
The team is also continuing to isolate viruses from different patients to monitor whether the virus is changing. ‘If the virus mutates, it may become more or less susceptible to antivirals, or may become more or less pathogenic,’ says Asst Prof Danielle Anderson from Duke-NUS Medical School’s Emerging Infectious Diseases Programme.
Efforts are ongoing to bring the Coalition for Epidemic Preparedness Innovations (CEPI), a Norway-based public-private coalition that facilitates vaccine development, on board so that testing and assessment of vaccine effectiveness can be initiated at the earliest.
Furthermore, in response to the fast evolving and changing landscape of COVID-19 outbreak, Duke-NUS is collaborating with biotech firms and research institutes to test their products and treatments against the live virus, although this is still in its preliminary stages. Most recently, it was announced that Duke-NUS would partner with San Diego-based Arcturus Therapeutics to develop a COVID-19 vaccine based on Arcturus Therapeutics’ STARR Technology™. The STARR™ platform uses self-replicating RNA and a nanoparticle delivery system to achieve protective responses at lower vaccine doses than typically needed. Asst Prof Anderson says that Duke-NUS is open to both collaborative and service contracts ‘as our interests are getting good products or treatments tested as fast as possible to help control the outbreak.’
Singapore has earned high praise for its handling of the COVID-19 outbreak so far. The outbreak comes at a time when biotech and medtech industries are rapidly expanding in the region, brought on by a growing talent pool of highly educated workers and initiatives from the government to provide capital, infrastructure and mentorship support for startups in this space. This isn’t purely by chance; the move to build local expertise in biotech and biomedical research has been deliberate from the start. ‘The first and most immediate step to control an outbreak is to detect and treat or manage [cases].’ says Dr Yee, ‘Being self-sufficient [in this respect] is important for Singapore.’
As a result, Singapore is now much better prepared to deal with outbreaks of infectious disease than it was 10 years ago. Nonetheless, fears of what more is to come as the situation worsens globally are keeping healthcare workers, policymakers and researchers on their toes.
 Numbers correct at time of publication
 DxD Hub is a national initiative led by A*ccelerate, the commercialisation arm of A*STAR.
 Reverse-transcription polymerase chain reaction (RT-PCR) tests detect the presence of specific RNA sequences by first converting the RNA to DNA, amplifying a DNA fragment of interest, then detecting the amplified product using DNA dyes.
We thank Dr Sidney Yee, Sam Dajani, Dr Damian Foo and Dr Danielle Anderson for their comments on ongoing research into COVID-19 and SARS-CoV-2. We are also grateful to Dr Daphne Ng and Dr Jolene Ho for facilitating these conversations.
This article was updated on 31st March 2020 to include the diagnostic kit developed by JN Medsys and update the number of confirmed cases.
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