Serveur d'exploration MERS

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From SARS to MERS, Thrusting Coronaviruses into the Spotlight

Identifieur interne : 001440 ( Pmc/Corpus ); précédent : 001439; suivant : 001441

From SARS to MERS, Thrusting Coronaviruses into the Spotlight

Auteurs : Zhiqi Song ; Yanfeng Xu ; Linlin Bao ; Ling Zhang ; Pin Yu ; Yajin Qu ; Hua Zhu ; Wenjie Zhao ; Yunlin Han ; Chuan Qin

Source :

RBID : PMC:6357155

Abstract

Coronaviruses (CoVs) have formerly been regarded as relatively harmless respiratory pathogens to humans. However, two outbreaks of severe respiratory tract infection, caused by the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), as a result of zoonotic CoVs crossing the species barrier, caused high pathogenicity and mortality rates in human populations. This brought CoVs global attention and highlighted the importance of controlling infectious pathogens at international borders. In this review, we focus on our current understanding of the epidemiology, pathogenesis, prevention, and treatment of SARS-CoV and MERS-CoV, as well as provides details on the pivotal structure and function of the spike proteins (S proteins) on the surface of each of these viruses. For building up more suitable animal models, we compare the current animal models recapitulating pathogenesis and summarize the potential role of host receptors contributing to diverse host affinity in various species. We outline the research still needed to fully elucidate the pathogenic mechanism of these viruses, to construct reproducible animal models, and ultimately develop countermeasures to conquer not only SARS-CoV and MERS-CoV, but also these emerging coronaviral diseases.


Url:
DOI: 10.3390/v11010059
PubMed: 30646565
PubMed Central: 6357155

Links to Exploration step

PMC:6357155

Le document en format XML

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<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
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<name sortKey="Zhang, Ling" sort="Zhang, Ling" uniqKey="Zhang L" first="Ling" last="Zhang">Ling Zhang</name>
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<nlm:aff id="af1-viruses-11-00059">Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
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<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
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<name sortKey="Yu, Pin" sort="Yu, Pin" uniqKey="Yu P" first="Pin" last="Yu">Pin Yu</name>
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<nlm:aff id="af1-viruses-11-00059">Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
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(Z.S.);
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(Y.X.);
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<nlm:aff id="af2-viruses-11-00059">NHC Key Laboratory of Human Disease Comparative Medicine, the Institute of Laboratory Animal Sciences, CAMS&PUMC, Beijing 100021, China</nlm:aff>
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<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
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<name sortKey="Qu, Yajin" sort="Qu, Yajin" uniqKey="Qu Y" first="Yajin" last="Qu">Yajin Qu</name>
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<nlm:aff id="af1-viruses-11-00059">Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
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<email>hnndwenjiezhao@163.com</email>
(W.Z.);
<email>18510165683@163.com</email>
(Y.H.)</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af2-viruses-11-00059">NHC Key Laboratory of Human Disease Comparative Medicine, the Institute of Laboratory Animal Sciences, CAMS&PUMC, Beijing 100021, China</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Zhu, Hua" sort="Zhu, Hua" uniqKey="Zhu H" first="Hua" last="Zhu">Hua Zhu</name>
<affiliation>
<nlm:aff id="af1-viruses-11-00059">Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
<email>songzhiqi1989@foxmail.com</email>
(Z.S.);
<email>xuyanf2009@163.com</email>
(Y.X.);
<email>bllmsl@aliyun.com</email>
(L.B.);
<email>zhangling@cnilas.org</email>
(L.Z.);
<email>pinyucau@gmail.com</email>
(P.Y.);
<email>quyj@cnilas.org</email>
(Y.Q.);
<email>zhuh@cnilas.org</email>
(H.Z.);
<email>hnndwenjiezhao@163.com</email>
(W.Z.);
<email>18510165683@163.com</email>
(Y.H.)</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af2-viruses-11-00059">NHC Key Laboratory of Human Disease Comparative Medicine, the Institute of Laboratory Animal Sciences, CAMS&PUMC, Beijing 100021, China</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Zhao, Wenjie" sort="Zhao, Wenjie" uniqKey="Zhao W" first="Wenjie" last="Zhao">Wenjie Zhao</name>
<affiliation>
<nlm:aff id="af1-viruses-11-00059">Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
<email>songzhiqi1989@foxmail.com</email>
(Z.S.);
<email>xuyanf2009@163.com</email>
(Y.X.);
<email>bllmsl@aliyun.com</email>
(L.B.);
<email>zhangling@cnilas.org</email>
(L.Z.);
<email>pinyucau@gmail.com</email>
(P.Y.);
<email>quyj@cnilas.org</email>
(Y.Q.);
<email>zhuh@cnilas.org</email>
(H.Z.);
<email>hnndwenjiezhao@163.com</email>
(W.Z.);
<email>18510165683@163.com</email>
(Y.H.)</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af2-viruses-11-00059">NHC Key Laboratory of Human Disease Comparative Medicine, the Institute of Laboratory Animal Sciences, CAMS&PUMC, Beijing 100021, China</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Han, Yunlin" sort="Han, Yunlin" uniqKey="Han Y" first="Yunlin" last="Han">Yunlin Han</name>
<affiliation>
<nlm:aff id="af1-viruses-11-00059">Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
<email>songzhiqi1989@foxmail.com</email>
(Z.S.);
<email>xuyanf2009@163.com</email>
(Y.X.);
<email>bllmsl@aliyun.com</email>
(L.B.);
<email>zhangling@cnilas.org</email>
(L.Z.);
<email>pinyucau@gmail.com</email>
(P.Y.);
<email>quyj@cnilas.org</email>
(Y.Q.);
<email>zhuh@cnilas.org</email>
(H.Z.);
<email>hnndwenjiezhao@163.com</email>
(W.Z.);
<email>18510165683@163.com</email>
(Y.H.)</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af2-viruses-11-00059">NHC Key Laboratory of Human Disease Comparative Medicine, the Institute of Laboratory Animal Sciences, CAMS&PUMC, Beijing 100021, China</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
</affiliation>
</author>
<author>
<name sortKey="Qin, Chuan" sort="Qin, Chuan" uniqKey="Qin C" first="Chuan" last="Qin">Chuan Qin</name>
<affiliation>
<nlm:aff id="af1-viruses-11-00059">Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
<email>songzhiqi1989@foxmail.com</email>
(Z.S.);
<email>xuyanf2009@163.com</email>
(Y.X.);
<email>bllmsl@aliyun.com</email>
(L.B.);
<email>zhangling@cnilas.org</email>
(L.Z.);
<email>pinyucau@gmail.com</email>
(P.Y.);
<email>quyj@cnilas.org</email>
(Y.Q.);
<email>zhuh@cnilas.org</email>
(H.Z.);
<email>hnndwenjiezhao@163.com</email>
(W.Z.);
<email>18510165683@163.com</email>
(Y.H.)</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af2-viruses-11-00059">NHC Key Laboratory of Human Disease Comparative Medicine, the Institute of Laboratory Animal Sciences, CAMS&PUMC, Beijing 100021, China</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="af3-viruses-11-00059">Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</nlm:aff>
</affiliation>
</author>
</analytic>
<series>
<title level="j">Viruses</title>
<idno type="eISSN">1999-4915</idno>
<imprint>
<date when="2019">2019</date>
</imprint>
</series>
</biblStruct>
</sourceDesc>
</fileDesc>
<profileDesc>
<textClass></textClass>
</profileDesc>
</teiHeader>
<front>
<div type="abstract" xml:lang="en">
<p>Coronaviruses (CoVs) have formerly been regarded as relatively harmless respiratory pathogens to humans. However, two outbreaks of severe respiratory tract infection, caused by the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), as a result of zoonotic CoVs crossing the species barrier, caused high pathogenicity and mortality rates in human populations. This brought CoVs global attention and highlighted the importance of controlling infectious pathogens at international borders. In this review, we focus on our current understanding of the epidemiology, pathogenesis, prevention, and treatment of SARS-CoV and MERS-CoV, as well as provides details on the pivotal structure and function of the spike proteins (S proteins) on the surface of each of these viruses. For building up more suitable animal models, we compare the current animal models recapitulating pathogenesis and summarize the potential role of host receptors contributing to diverse host affinity in various species. We outline the research still needed to fully elucidate the pathogenic mechanism of these viruses, to construct reproducible animal models, and ultimately develop countermeasures to conquer not only SARS-CoV and MERS-CoV, but also these emerging coronaviral diseases.</p>
</div>
</front>
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<pmc-dir>properties open_access</pmc-dir>
<front>
<journal-meta>
<journal-id journal-id-type="nlm-ta">Viruses</journal-id>
<journal-id journal-id-type="iso-abbrev">Viruses</journal-id>
<journal-id journal-id-type="publisher-id">viruses</journal-id>
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<issn pub-type="epub">1999-4915</issn>
<publisher>
<publisher-name>MDPI</publisher-name>
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</journal-meta>
<article-meta>
<article-id pub-id-type="pmid">30646565</article-id>
<article-id pub-id-type="pmc">6357155</article-id>
<article-id pub-id-type="doi">10.3390/v11010059</article-id>
<article-id pub-id-type="publisher-id">viruses-11-00059</article-id>
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<subj-group subj-group-type="heading">
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<title-group>
<article-title>From SARS to MERS, Thrusting Coronaviruses into the Spotlight</article-title>
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<xref ref-type="aff" rid="af1-viruses-11-00059">1</xref>
<xref ref-type="aff" rid="af2-viruses-11-00059">2</xref>
<xref ref-type="aff" rid="af3-viruses-11-00059">3</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Zhao</surname>
<given-names>Wenjie</given-names>
</name>
<xref ref-type="aff" rid="af1-viruses-11-00059">1</xref>
<xref ref-type="aff" rid="af2-viruses-11-00059">2</xref>
<xref ref-type="aff" rid="af3-viruses-11-00059">3</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Han</surname>
<given-names>Yunlin</given-names>
</name>
<xref ref-type="aff" rid="af1-viruses-11-00059">1</xref>
<xref ref-type="aff" rid="af2-viruses-11-00059">2</xref>
<xref ref-type="aff" rid="af3-viruses-11-00059">3</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Qin</surname>
<given-names>Chuan</given-names>
</name>
<xref ref-type="aff" rid="af1-viruses-11-00059">1</xref>
<xref ref-type="aff" rid="af2-viruses-11-00059">2</xref>
<xref ref-type="aff" rid="af3-viruses-11-00059">3</xref>
<xref rid="c1-viruses-11-00059" ref-type="corresp">*</xref>
</contrib>
</contrib-group>
<aff id="af1-viruses-11-00059">
<label>1</label>
Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences (CAMS) & Comparative Medicine Centre, Peking Union Medical Collage (PUMC), Beijing 100021, China;
<email>songzhiqi1989@foxmail.com</email>
(Z.S.);
<email>xuyanf2009@163.com</email>
(Y.X.);
<email>bllmsl@aliyun.com</email>
(L.B.);
<email>zhangling@cnilas.org</email>
(L.Z.);
<email>pinyucau@gmail.com</email>
(P.Y.);
<email>quyj@cnilas.org</email>
(Y.Q.);
<email>zhuh@cnilas.org</email>
(H.Z.);
<email>hnndwenjiezhao@163.com</email>
(W.Z.);
<email>18510165683@163.com</email>
(Y.H.)</aff>
<aff id="af2-viruses-11-00059">
<label>2</label>
NHC Key Laboratory of Human Disease Comparative Medicine, the Institute of Laboratory Animal Sciences, CAMS&PUMC, Beijing 100021, China</aff>
<aff id="af3-viruses-11-00059">
<label>3</label>
Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious, Beijing 100021, China</aff>
<author-notes>
<corresp id="c1-viruses-11-00059">
<label>*</label>
Correspondence:
<email>qinchuan@pumc.edu.cn</email>
</corresp>
</author-notes>
<pub-date pub-type="epub">
<day>14</day>
<month>1</month>
<year>2019</year>
</pub-date>
<pub-date pub-type="collection">
<month>1</month>
<year>2019</year>
</pub-date>
<volume>11</volume>
<issue>1</issue>
<elocation-id>59</elocation-id>
<history>
<date date-type="received">
<day>16</day>
<month>12</month>
<year>2018</year>
</date>
<date date-type="accepted">
<day>09</day>
<month>1</month>
<year>2019</year>
</date>
</history>
<permissions>
<copyright-statement>© 2019 by the authors.</copyright-statement>
<copyright-year>2019</copyright-year>
<license license-type="open-access">
<license-p>Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (
<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>
).</license-p>
</license>
</permissions>
<abstract>
<p>Coronaviruses (CoVs) have formerly been regarded as relatively harmless respiratory pathogens to humans. However, two outbreaks of severe respiratory tract infection, caused by the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), as a result of zoonotic CoVs crossing the species barrier, caused high pathogenicity and mortality rates in human populations. This brought CoVs global attention and highlighted the importance of controlling infectious pathogens at international borders. In this review, we focus on our current understanding of the epidemiology, pathogenesis, prevention, and treatment of SARS-CoV and MERS-CoV, as well as provides details on the pivotal structure and function of the spike proteins (S proteins) on the surface of each of these viruses. For building up more suitable animal models, we compare the current animal models recapitulating pathogenesis and summarize the potential role of host receptors contributing to diverse host affinity in various species. We outline the research still needed to fully elucidate the pathogenic mechanism of these viruses, to construct reproducible animal models, and ultimately develop countermeasures to conquer not only SARS-CoV and MERS-CoV, but also these emerging coronaviral diseases.</p>
</abstract>
<kwd-group>
<kwd>coronaviruses</kwd>
<kwd>SARS-CoV</kwd>
<kwd>MERS-CoV</kwd>
<kwd>spike proteins</kwd>
<kwd>animal model</kwd>
<kwd>prevention and treatment</kwd>
</kwd-group>
</article-meta>
</front>
<body>
<sec id="sec1-viruses-11-00059">
<title>1. Introduction</title>
<p>Before the first outbreak of severe acute respiratory syndrome (SARS), a limited number of coronaviruses were known to be circulating in humans, causing only mild illnesses, such as the common cold [
<xref rid="B1-viruses-11-00059" ref-type="bibr">1</xref>
]. Following the 2003 SARS pandemic [
<xref rid="B2-viruses-11-00059" ref-type="bibr">2</xref>
,
<xref rid="B3-viruses-11-00059" ref-type="bibr">3</xref>
], it became apparent that coronaviruses could cross the species barrier and cause life-threatening infections in humans. Therefore, further attention needs to be paid to these new coronaviruses.</p>
<p>The 21st century has seen the worldwide spread of two previously unrecognized coronaviruses, the severe acute respiratory syndrome coronavirus (SARS-CoV) [
<xref rid="B4-viruses-11-00059" ref-type="bibr">4</xref>
] and Middle East respiratory syndrome coronavirus (MERS-CoV), both of which are highly pathogenic. Starting from November 2002 in China [
<xref rid="B5-viruses-11-00059" ref-type="bibr">5</xref>
], there have been unprecedented nosocomial transmissions from person to person of SARS-CoV, accompanied by high fatality rates. A united global effort led to the rapid identification of the SARS coronavirus and remarkable scientific advancements in epidemic prevention. Additionally, the zoonotic transmission of SARS from December 2003 to January 2004 [
<xref rid="B6-viruses-11-00059" ref-type="bibr">6</xref>
] provided insight for researchers into the origin of this novel coronavirus. Notably, the SARS pandemic was declared to be over in 2004 when no more infections in patients were being detected. Subsequently, certain SARS-CoV-like viruses found in bats demonstrated the ability to infect human cells without prior adaptation [
<xref rid="B7-viruses-11-00059" ref-type="bibr">7</xref>
,
<xref rid="B8-viruses-11-00059" ref-type="bibr">8</xref>
] which indicates the possibility of the re-emergence of SARS-CoV or SARS-CoV-like viruses.</p>
<p>A decade later in June 2012, another highly pathogenic and novel coronavirus, MERS-CoV, was isolated from the sputum of a male patient who died from acute pneumonia and renal failure in Saudi Arabia [
<xref rid="B9-viruses-11-00059" ref-type="bibr">9</xref>
]. Nosocomial infections were reported, and international travel led to the transmission of MERS-CoV to countries outside of the Arabian Peninsula, causing it to become a global pathophoresis. In May 2015, an outbreak of MERS occurred in South Korea due to an individual returning from the Middle East [
<xref rid="B10-viruses-11-00059" ref-type="bibr">10</xref>
]. Based on the lessons learned from managing SARS-CoV prevalence over the last decade, tremendous progress toward unraveling the biological characteristics of MERS-CoV has been achieved at an unprecedented speed. Scientific advancements have allowed for rapid and systemic progress in our understanding of the epidemiology and pathogenesis of MERS-CoV.</p>
<p>SARS-CoV and MERS-CoV share several important common features that contribute to nosocomial transmission, preferential viral replication in the lower respiratory tract, and viral immunopathology. This review highlights the epidemiology and pathogenesis of these viruses, including our current understanding of their biological characteristics, their transmission, and their replication in the host. The spike proteins (S proteins) of CoVs play pivotal roles in viral infection and pathogenesis. As critical surface-located trimeric glycoproteins of CoVs, they guide entry into host cells. In this review, we summarize the structure and function of the S proteins and therapeutics designed to target them. Moreover, we will explore how CoV–host interactions cause pathogenic outcomes and discuss potential treatment options, as well as describe recent mammalian models that closely recapitulate the pathogenic process and have contributed to the development of prevention and treatment strategies for SARS-CoV and MERS-CoV. Although several potential therapies have been identified with SARS and MERS in animal and in vitro models, human clinical trials remain lacking, hindering the advancement of these potential countermeasures.</p>
</sec>
<sec id="sec2-viruses-11-00059">
<title>2. Epidemiology of SARS-CoV and MERS-CoV</title>
<p>Prior to the outbreaks of SARS and MERS [
<xref rid="B2-viruses-11-00059" ref-type="bibr">2</xref>
,
<xref rid="B9-viruses-11-00059" ref-type="bibr">9</xref>
], the clinical importance and epidemic possibility of CoVs had been recognized by researchers, (
<xref rid="viruses-11-00059-t001" ref-type="table">Table 1</xref>
). In 2002, a SARS epidemic that originated in Guangdong Province in China resulted in 916 deaths among more than 8098 patients in 29 countries [
<xref rid="B11-viruses-11-00059" ref-type="bibr">11</xref>
], identifying SARS as the first new infectious disease of the 21st century. Ten years later, the World Health Organization (WHO) published 2254 laboratory-confirmed cases of MERS-CoV that occurred from 2012 to 16 September 2018, with at least 800 deaths in 27 countries. Remarkably, more than 80% of recent research into the virology and genetics of this infection indicated that bats could be the possible natural reservoirs of both SARS and MERS-CoV. Palm civets [
<xref rid="B12-viruses-11-00059" ref-type="bibr">12</xref>
] and dromedary camels [
<xref rid="B13-viruses-11-00059" ref-type="bibr">13</xref>
] are also possible intermediary hosts of SARS and MERS, respectively, before dissemination to humans [
<xref rid="B14-viruses-11-00059" ref-type="bibr">14</xref>
].</p>
<p>The transmission mechanism of SARS-CoV and MERS-CoV has yet to be fully understood. For transmission from animals to humans, direct contact with the intermediary host might be one route. Recent reports demonstrated that camel workers in Saudi Arabia with high prevalence of MERS-CoV infection may contribute to the transmission of MERS [
<xref rid="B15-viruses-11-00059" ref-type="bibr">15</xref>
]. Some customs and habits may also be conducive to transmission, such as the consumption of milk, urine, or uncooked meat. In this way, MERS-CoV was transmitted from dromedary camels directly to humans, principally in the Arabian Peninsula, and this is considered to be the main route of transmission from animals to humans, causing significant morbidity and mortality [
<xref rid="B16-viruses-11-00059" ref-type="bibr">16</xref>
,
<xref rid="B17-viruses-11-00059" ref-type="bibr">17</xref>
]. Human-to-human spread has also been detected, especially through nosocomial transmission. Delays in diagnosis in hospitals might lead to secondary cases among healthcare workers, family members, or other patients sharing rooms [
<xref rid="B18-viruses-11-00059" ref-type="bibr">18</xref>
,
<xref rid="B19-viruses-11-00059" ref-type="bibr">19</xref>
,
<xref rid="B20-viruses-11-00059" ref-type="bibr">20</xref>
,
<xref rid="B21-viruses-11-00059" ref-type="bibr">21</xref>
,
<xref rid="B22-viruses-11-00059" ref-type="bibr">22</xref>
]. Among the reported cases of SARS, 22% were healthcare workers in China and more than 40% were healthcare workers in Canada [
<xref rid="B23-viruses-11-00059" ref-type="bibr">23</xref>
]. Nosocomial transmission for MERS has similarly been seen in the Middle East [
<xref rid="B16-viruses-11-00059" ref-type="bibr">16</xref>
] and in the Republic of Korea [
<xref rid="B22-viruses-11-00059" ref-type="bibr">22</xref>
]. Outbreaks in other countries all resulted from the reported cases in the Middle East or North Africa, and transmission was the result of international travel. Both SARS and MERS caused large outbreaks with significant public health and economic consequences.</p>
</sec>
<sec id="sec3-viruses-11-00059">
<title>3. Pathogenesis of SARS-CoV and MERS-CoV</title>
<p>Although our current understanding of the pathogenesis of the SARS-CoV and MERS-CoV infection remains unclear, we summarize what is presently known (
<xref rid="viruses-11-00059-t002" ref-type="table">Table 2</xref>
).</p>
<p>Coronaviruses are the largest kind of positive-strand RNA viruses (26–32 kb) as they are about 125 nm in diameter [
<xref rid="B24-viruses-11-00059" ref-type="bibr">24</xref>
], and comprise four genera (alpha-, beta-, gamma-, and delta-coronavirus) [
<xref rid="B25-viruses-11-00059" ref-type="bibr">25</xref>
]. Currently, six human CoVs (HCoVs) have been confirmed: HCoV-NL63 and HCoV-229E, which belong to the alpha-coronavirus genus; and HCoV-OC43, HCoV-HKU1, SARS-CoV, and MERS-CoV, which belong to the beta-coronavirus genus. SARS-CoV and MERS-CoV are the two major causes of severe pneumonia in humans and share some common coronavirus structural characteristics. Similarly, their genomic organization is typical of coronaviruses, having an enveloped, single, positive-stranded RNA genome that encodes four major viral structural proteins, namely spike (S), envelope (E), membrane (M), and nucleocapsid (N) proteins 3–5, that follow the characteristic gene order [5′-replicase (
<italic>rep</italic>
gene), spike (S), envelope (E), membrane (M), nucleocapsid (N)-3′] with short untranslated regions at both termini (
<xref ref-type="fig" rid="viruses-11-00059-f001">Figure 1</xref>
). The viral membrane contains S, E, and M proteins, and the spike protein plays a vital functional role in viral entry. The
<italic>rep</italic>
gene encodes the non-structural protein and constitutes approximately two-thirds of the genome at the 5′ end. In detail, the S protein is in charge of receptor-binding and subsequent viral entry into host cells, and is therefore a major therapeutic target [
<xref rid="B26-viruses-11-00059" ref-type="bibr">26</xref>
,
<xref rid="B27-viruses-11-00059" ref-type="bibr">27</xref>
]. The M and E proteins play important roles in viral assembly, and the N protein is necessary for RNA synthesis.</p>
<p>The SARS-CoV genome has 29,727 nucleotides in length, including 11 open reading frames (ORFs). The SARS-CoV
<italic>rep</italic>
gene, containing about two-thirds of the genome, encodes at least two polyproteins (encoded by ORF1a and ORF1b) that undergo the process of cotranslational proteolysis. Between ORF1b and S of group 2 and some group 3 coronaviruses, there is a gene that encodes hemagglutinin-esterase [
<xref rid="B4-viruses-11-00059" ref-type="bibr">4</xref>
], while this was not detected in SARS-CoV. This virus is significantly different from previously reported coronaviruses for many reasons, such as the short anchor of the S protein, the specific number and location of small ORFs, and the presence of only one copy of PLP
<sup>pro</sup>
.</p>
<p>The MERS-CoV genome is larger than that of SARS-CoV at 30,119 nucleotides in length, and comprises a 5′ terminal cap structure, along with a poly (A) tail at the 3′ end, as well as the
<italic>rep</italic>
gene containing 16 non-structural proteins (nsp1–16) at the 5′ end of the genome. Four structural proteins (S, E, M, and N) and five accessory proteins (ORF3, ORF4a, ORF4b, ORF5, and ORF8) constitute about 10 kb at the 3′ end of the genome. Unlike some other beta-coronaviruses, the MERS-CoV genome does not encode a hemagglutinin-esterase (HE) protein [
<xref rid="B1-viruses-11-00059" ref-type="bibr">1</xref>
]. Genomic analysis of MERS-CoV implies the potential for genetic recombination during a MERS-CoV outbreak [
<xref rid="B9-viruses-11-00059" ref-type="bibr">9</xref>
]. MERS-CoV and SARS-CoV possess five and eight accessory proteins, respectively, which might help the virus evade the immune system by being harmful to the innate immune response. These differences might lead to greater sensitivity to the effects of induction and signaling of type 1 interferons (IFNs) in MERS-CoV than SARS-CoV.</p>
</sec>
<sec id="sec4-viruses-11-00059">
<title>4. Comparative Pathology and Life Cycles of SARS-CoV and MERS-CoV</title>
<p>Both SARS and MERS cause severe pneumonia resulting from these novel coronaviruses, sharing some similarities in their pathogenesis (
<xref ref-type="fig" rid="viruses-11-00059-f002">Figure 2</xref>
) [
<xref rid="B28-viruses-11-00059" ref-type="bibr">28</xref>
].</p>
<p>SARS is an emerging infectious viral disease characterized by severe clinical manifestations of the lower respiratory tract, resulting in diffuse alveolar damage. SARS-CoV spreads through respiratory secretions, such as droplets, via direct person-to-person contact. Upon exposure of the host to the virus, the virus binds to cells expressing the virus receptors, of which the angiotensin-converting enzyme 2 (ACE2) is one of the main receptors, and CD209L is an alternative receptor with a much lower affinity [
<xref rid="B29-viruses-11-00059" ref-type="bibr">29</xref>
]. In the respiratory tract, ACE2 is widely expressed on the epithelial cells of alveoli, trachea, bronchi, bronchial serous glands [
<xref rid="B30-viruses-11-00059" ref-type="bibr">30</xref>
], and alveolar monocytes and macrophages [
<xref rid="B31-viruses-11-00059" ref-type="bibr">31</xref>
]. The virus enters and replicates in these target cells. The mature virions are then released from primary cells and infect new target cells [
<xref rid="B32-viruses-11-00059" ref-type="bibr">32</xref>
]. Furthermore, as a surface molecule, ACE2 is also diffusely localized on the endothelial cells of arteries and veins, the mucosal cells of the intestines, tubular epithelial cells of the kidneys, epithelial cells of the renal tubules, and cerebral neurons and immune cells, providing a variety of susceptible cells to SARS-CoV [
<xref rid="B33-viruses-11-00059" ref-type="bibr">33</xref>
,
<xref rid="B34-viruses-11-00059" ref-type="bibr">34</xref>
]. Respiratory secretions, urine, stools, and sweat from patients with SARS contain infective viral particles, which may be excreted into and contaminate the environment. Atypical pneumonia with rapid respiratory deterioration and failure can be induced by SARS-CoV infection because of increased levels of activated proinflammatory chemokines and cytokines [
<xref rid="B35-viruses-11-00059" ref-type="bibr">35</xref>
].</p>
<p>For MERS-CoV infection of humans, the primary receptor is a multifunctional cell surface protein, dipeptidyl peptidase 4 (DPP4, also known as CD26) [
<xref rid="B36-viruses-11-00059" ref-type="bibr">36</xref>
], which is widely expressed on epithelial cells in the kidney, alveoli, small intestine, liver, and prostate, and on activated leukocytes [
<xref rid="B37-viruses-11-00059" ref-type="bibr">37</xref>
]. Consistent with this, MERS-CoV can infect several human cell lines, including lower respiratory, kidney, intestinal, and liver cells, as well as histiocytes, as shown by a cell-line susceptibility study [
<xref rid="B38-viruses-11-00059" ref-type="bibr">38</xref>
], indicating that the range of MERS-CoV tissue tropism in vitro was broader than that of any other CoV. MERS-CoV causes acute, highly lethal pneumonia and renal dysfunction with various clinical symptoms, including—but not restricted to—fever, cough, sore throat, myalgia, chest pain, diarrhea, vomiting, and abdominal pain [
<xref rid="B39-viruses-11-00059" ref-type="bibr">39</xref>
,
<xref rid="B40-viruses-11-00059" ref-type="bibr">40</xref>
]. Lung infection in the MERS animal model demonstrated infiltration of neutrophils and macrophages and alveolar edema [
<xref rid="B41-viruses-11-00059" ref-type="bibr">41</xref>
]. The entry receptor (DPP4) for MERS-CoV is also highly expressed in the kidney, causing renal dysfunctions by either hypoxic damage or direct infection of the epithelia [
<xref rid="B42-viruses-11-00059" ref-type="bibr">42</xref>
]. Remarkably, unlike SARS-CoV, MERS-CoV has the ability to infect human dendritic cells [
<xref rid="B43-viruses-11-00059" ref-type="bibr">43</xref>
] and macrophages [
<xref rid="B44-viruses-11-00059" ref-type="bibr">44</xref>
] in vitro, thus helping the virus to disrupt the immune system. T cells are another target for MERS-CoV because of their high amounts of CD26 [
<xref rid="B45-viruses-11-00059" ref-type="bibr">45</xref>
]. This virus might deregulate antiviral T-cell responses due to the stimulation of T-cell apoptosis [
<xref rid="B45-viruses-11-00059" ref-type="bibr">45</xref>
,
<xref rid="B46-viruses-11-00059" ref-type="bibr">46</xref>
]. MERS-CoV might also lead to immune dysregulation [
<xref rid="B47-viruses-11-00059" ref-type="bibr">47</xref>
] by stimulating attenuated innate immune responses, with delayed proinflammatory cytokine induction in vitro and in vivo [
<xref rid="B44-viruses-11-00059" ref-type="bibr">44</xref>
,
<xref rid="B48-viruses-11-00059" ref-type="bibr">48</xref>
,
<xref rid="B49-viruses-11-00059" ref-type="bibr">49</xref>
].</p>
</sec>
<sec id="sec5-viruses-11-00059">
<title>5. SARS and MERS-CoV Spike Protein: A Key Target for Antivirals</title>
<sec id="sec5dot1-viruses-11-00059">
<title>5.1. Structure of the SARS-CoV and MERS-CoV Spike Protein</title>
<p>Trimers of the S protein make up the spikes of SARS-CoV and provide the formation of a 1255-amino-acids-length surface glycoprotein precursor. Most of the protein and the amino terminus are situated on the outside of the virus particle or the cell surface [
<xref rid="B50-viruses-11-00059" ref-type="bibr">50</xref>
]. The expected structure of the S protein comprises four parts: a signal peptide located at the N terminus from amino acids 1 to 12, an extracellular domain from amino acids 13 to 1195, a transmembrane domain from amino acids 1196 to 1215, and an intracellular domain from amino acids 1216 to 1255. Proteases such as factor Xa, trypsin, and cathepsin L cleave the SARS-CoV S protein into two subunits, the S1 and S2 subunits. A minimal receptor-binding domain (RBD) located in the S1 subunit (amino acids 318–510) can combine with the host cell receptor, ACE2. The RBD displays a concave surface during interaction with the receptor. The entire receptor-binding loop, known as the receptor-binding motif (RBM) (amino acids 424–494), is located on the RBD and is responsible for complete contact with ACE2. Importantly, two residues in the RBM at positions 479 and 487 determine the progression of the SARS disease and the tropism of SARS-CoV [
<xref rid="B51-viruses-11-00059" ref-type="bibr">51</xref>
,
<xref rid="B52-viruses-11-00059" ref-type="bibr">52</xref>
]. Recent studies using civets, mice, and rats demonstrated that any change in these two residues might improve animal-to-human or human-to-human transmission and facilitate efficient cross-species infection [
<xref rid="B53-viruses-11-00059" ref-type="bibr">53</xref>
]. The S2 subunit mediates the fusion between SARS-CoV and target cells, and includes the heptad repeat 1 (HR1) and HR2 domains, whose HR1 region is longer than the HR2 region.</p>
<p>Similar to SARS-CoV, during the infection process, the S protein of MERS-CoV is cleaved into a receptor-binding subunit S1 and a membrane-fusion subunit S2 [
<xref rid="B54-viruses-11-00059" ref-type="bibr">54</xref>
,
<xref rid="B55-viruses-11-00059" ref-type="bibr">55</xref>
,
<xref rid="B56-viruses-11-00059" ref-type="bibr">56</xref>
,
<xref rid="B57-viruses-11-00059" ref-type="bibr">57</xref>
]. The MERS-CoV S1 subunit also includes an RBD, mediating the attachment between virus and target cells [
<xref rid="B54-viruses-11-00059" ref-type="bibr">54</xref>
,
<xref rid="B55-viruses-11-00059" ref-type="bibr">55</xref>
,
<xref rid="B58-viruses-11-00059" ref-type="bibr">58</xref>
,
<xref rid="B59-viruses-11-00059" ref-type="bibr">59</xref>
]. Unlike SARS-CoV, MERS-CoV requires DPP4 (also known as CD26) as its cellular receptor [
<xref rid="B60-viruses-11-00059" ref-type="bibr">60</xref>
,
<xref rid="B61-viruses-11-00059" ref-type="bibr">61</xref>
] but not ACE2. The RBDs of MERS-CoV and SARS-CoV differ, although they share a high degree of structural similarity in their core subdomains, explaining the different critical receptors noted above [
<xref rid="B57-viruses-11-00059" ref-type="bibr">57</xref>
,
<xref rid="B62-viruses-11-00059" ref-type="bibr">62</xref>
]. The core subdomain of RBD is stabilized by three disulfide bonds, and includes a five-stranded antiparallel β-sheet and several connecting helices. The RBM comprises a four-stranded antiparallel β-sheet for connecting to the core via loops [
<xref rid="B57-viruses-11-00059" ref-type="bibr">57</xref>
,
<xref rid="B62-viruses-11-00059" ref-type="bibr">62</xref>
]. Two N-linked glycans, N410 and N487, are seated in the core and RBM, respectively. Particularly, the residues 484–567 of RBM take charge of interacting with the extracellular β-propeller domain of DPP4. The fusion core formation of MERS-CoV resembles that of SARS-CoV; however, it is different from that of other coronaviruses, such as the mouse hepatitis virus (MHV) and HCoV-NL63 [
<xref rid="B63-viruses-11-00059" ref-type="bibr">63</xref>
,
<xref rid="B64-viruses-11-00059" ref-type="bibr">64</xref>
,
<xref rid="B65-viruses-11-00059" ref-type="bibr">65</xref>
,
<xref rid="B66-viruses-11-00059" ref-type="bibr">66</xref>
].</p>
</sec>
<sec id="sec5dot2-viruses-11-00059">
<title>5.2. Functions of the SARS-CoV and MERS-CoV S Protein</title>
<p>The SARS-CoV S protein plays pivotal roles in viral infection and pathogenesis [
<xref rid="B67-viruses-11-00059" ref-type="bibr">67</xref>
,
<xref rid="B68-viruses-11-00059" ref-type="bibr">68</xref>
]. The S1 subunit recognizes and binds to host receptors, and the subsequent conformational changes in the S2 subunit mediate fusion between the viral envelope and the host cell membrane [
<xref rid="B69-viruses-11-00059" ref-type="bibr">69</xref>
,
<xref rid="B70-viruses-11-00059" ref-type="bibr">70</xref>
]. The RBD in the S1 subunit is responsible for virus binding to host cell receptors [
<xref rid="B61-viruses-11-00059" ref-type="bibr">61</xref>
,
<xref rid="B70-viruses-11-00059" ref-type="bibr">70</xref>
,
<xref rid="B71-viruses-11-00059" ref-type="bibr">71</xref>
]. ACE2 is a functional receptor for SARS-CoV that makes contact with 14 amino acids in the RBD of SARS-CoV among its 18 residues [
<xref rid="B53-viruses-11-00059" ref-type="bibr">53</xref>
]. The RBD in the S1 subunit is responsible for virus binding to host cell receptors [
<xref rid="B61-viruses-11-00059" ref-type="bibr">61</xref>
,
<xref rid="B70-viruses-11-00059" ref-type="bibr">70</xref>
,
<xref rid="B71-viruses-11-00059" ref-type="bibr">71</xref>
]. Position R453 in the RBD and position K341 in ACE2 play indispensable roles in complex formation [
<xref rid="B72-viruses-11-00059" ref-type="bibr">72</xref>
]. Furthermore, the N479 and T487 in the RBD of the S protein are pivotal positions for the affinity with ACE2 [
<xref rid="B52-viruses-11-00059" ref-type="bibr">52</xref>
], and R441 or D454 in the RBD influences the antigenic structure and binding activity between RBD and ACE2 [
<xref rid="B73-viruses-11-00059" ref-type="bibr">73</xref>
]. From a pre-fusion structure to a post-fusion structure, binding of the RBD in the S1 subunit to the receptor ACE2 stimulates a conformational change in S2. Accordingly, the supposed fusion peptide (amino acids 770–788) [
<xref rid="B74-viruses-11-00059" ref-type="bibr">74</xref>
] builds in the target cell membrane of the host. Meanwhile, a six-helix bundle fusion core structure is made up by the HR1 and HR2 domains for bringing the viral envelope and the target cell membrane into close proximity and contributing to fusion [
<xref rid="B74-viruses-11-00059" ref-type="bibr">74</xref>
]. Resembling the S2 subunit of SARS-CoV, the MERS-CoV S2 subunit is in charge of membrane fusion. The HR1 and HR2 regions in S2 play essential and complementary roles [
<xref rid="B56-viruses-11-00059" ref-type="bibr">56</xref>
,
<xref rid="B63-viruses-11-00059" ref-type="bibr">63</xref>
]. Furthermore, SARS-CoV displays an alternative method of binding to the host cell via other potential receptors. Dendritic cell-specific intercellular adhesion molecule-3-grabbing non-integrin (DC-SIGN) and/or liver/lymph node-SIGN (L-SIGN) are two examples of such receptors [
<xref rid="B29-viruses-11-00059" ref-type="bibr">29</xref>
,
<xref rid="B75-viruses-11-00059" ref-type="bibr">75</xref>
]. Seven residue sites, at positions 109, 118, 119, 158, 227, 589, and 699 of the S protein displaying asparagine-linked glycosylation are crucial for DC-SIGN or L-SIGN-mediated virus entry. These residues, unlike those of the ACE2-binding domain, function independently of ACE2 [
<xref rid="B76-viruses-11-00059" ref-type="bibr">76</xref>
].</p>
</sec>
<sec id="sec5dot3-viruses-11-00059">
<title>5.3. Vaccines Based on the SARS-CoV and MERS-CoV S Protein</title>
<p>In order to control the outbreak of viruses, vaccinations were developed against SARS-CoV and MERS-CoV. There are various approaches of different vaccines, and the development and advantages/disadvantages of these are listed in
<xref rid="viruses-11-00059-t003" ref-type="table">Table 3</xref>
(this table includes updates about SARS-CoV and MERS-CoV since 2013; SARS-CoV-related parts were modified by Graham et al. in Nature Reviews Microbiology, 2013 [
<xref rid="B77-viruses-11-00059" ref-type="bibr">77</xref>
]).</p>
<p>Importantly, among all the functional/non-functional structural proteins of SARS-CoV and MERS-CoV, the S protein is the principal antigenic component that induces antibodies to block virus-binding, stimulate host immune responses, fuse or neutralize antibodies and/or protect the immune system against virus infection. Therefore, the S protein has been selected as a significant target for the development of vaccines. It has been noted that antibodies raised against subunit S1 (amino acids 485–625) or S2 (amino acids 1029–1192) neutralize infection by SARS-CoV strains in Vero E6 cells [
<xref rid="B78-viruses-11-00059" ref-type="bibr">78</xref>
,
<xref rid="B79-viruses-11-00059" ref-type="bibr">79</xref>
]. Researchers have constructed an attenuated parainfluenza virus encoding the full-length S protein of the SARS-CoV Urbani strain for the vaccination of African green monkeys. This vaccine could protect monkeys from subsequent homologous SARS-CoV infection, demonstrating highly effective immunization with the S protein [
<xref rid="B80-viruses-11-00059" ref-type="bibr">80</xref>
]. Other studies in a mouse model structured a DNA vaccine encoding the full-length S protein of the SARS-CoV Urbani strain that not only induced T-cell and neutralizing-antibody responses, but also stimulated protective immunity [
<xref rid="B81-viruses-11-00059" ref-type="bibr">81</xref>
]. Furthermore, monkeys or mice were vaccinated with a highly attenuated, modified vaccine virus, Ankara, encoding the full-length S protein of the SARS-CoV strain HKU39849 or Urbani [
<xref rid="B82-viruses-11-00059" ref-type="bibr">82</xref>
]. However, full-length S protein-based SARS vaccines may induce harmful immune responses, causing liver damage in the vaccinated animals or enhancing infection after being challenged with homologous SARS-CoV [
<xref rid="B83-viruses-11-00059" ref-type="bibr">83</xref>
,
<xref rid="B84-viruses-11-00059" ref-type="bibr">84</xref>
]. Researchers are thus concerned about the safety and ultimate protective efficacy of vaccines that include the full-length SARS-CoV S protein.</p>
<p>There are still no commercial vaccines available against MERS-CoV [
<xref rid="B26-viruses-11-00059" ref-type="bibr">26</xref>
]. Multiple vaccine candidates targeting the S protein, which is responsible for viral entry, have been developed, including subunit vaccines [
<xref rid="B85-viruses-11-00059" ref-type="bibr">85</xref>
,
<xref rid="B86-viruses-11-00059" ref-type="bibr">86</xref>
], recombinant vector vaccines [
<xref rid="B87-viruses-11-00059" ref-type="bibr">87</xref>
,
<xref rid="B88-viruses-11-00059" ref-type="bibr">88</xref>
], and DNA vaccines [
<xref rid="B89-viruses-11-00059" ref-type="bibr">89</xref>
,
<xref rid="B90-viruses-11-00059" ref-type="bibr">90</xref>
]. Importantly, compared with other regions of the S protein, the RBD fragment induced the highest-titer IgG antibodies in mice [
<xref rid="B85-viruses-11-00059" ref-type="bibr">85</xref>
]. Modified vaccines, including recombinant vectors of Ankara and adenoviruses expressing the MERS-CoV S glycoprotein, showed immunogenicity in mice [
<xref rid="B25-viruses-11-00059" ref-type="bibr">25</xref>
]. Attenuated live vaccines also showed a protective function, but there were concerns regarding the degree of attenuation [
<xref rid="B91-viruses-11-00059" ref-type="bibr">91</xref>
]. After intranasal vaccination with the CoV N protein, airway memory CD4 T cells were generated and mediated the protection following a CoV challenge [
<xref rid="B92-viruses-11-00059" ref-type="bibr">92</xref>
]. These cells could induce anti-viral innate responses at an early stage of infection, and facilitated CD8 T-cell responses by stimulating recombinant dendritic cell migration and CD8 T-cell mobilization [
<xref rid="B92-viruses-11-00059" ref-type="bibr">92</xref>
]. The stimulation of airway memory CD4 T cells should be regarded as an essential part of any HCoV vaccine strategy, because these CD4 T cells target a conserved epitope within the N protein that cross-reacts with several other CoVs [
<xref rid="B92-viruses-11-00059" ref-type="bibr">92</xref>
]. Furthermore, DNA vaccines expressing the MERS-CoV S1 gene produced antigen-specific humoral and cellular immune responses in mice [
<xref rid="B89-viruses-11-00059" ref-type="bibr">89</xref>
].</p>
</sec>
<sec id="sec5dot4-viruses-11-00059">
<title>5.4. S Protein-Based Therapeutics for SARS-CoV and MERS-CoV</title>
<p>Despite the presence of extensive research reporting on SARS-CoV and MERS-CoV therapies, it was not possible to establish whether treatments benefited patients during their outbreak. In the absence of fundamental, clinically proven, effective antiviral therapy against SARS-CoV and MERS-CoV, patients mainly receive supportive care supplemented by diverse combinations of drugs. Several approaches are being considered to treat infections of SARS-CoV [
<xref rid="B113-viruses-11-00059" ref-type="bibr">113</xref>
] and MERS-CoV (
<xref rid="viruses-11-00059-t004" ref-type="table">Table 4</xref>
, MERS-CoV-related table previously reviewed by de Wit et al. in Nature Reviews Microbiology, 2016 [
<xref rid="B10-viruses-11-00059" ref-type="bibr">10</xref>
]), including the use of antibodies, IFNs, and inhibitors of viral and host proteases.</p>
<p>The vital role of the S protein of SARS-CoV makes this protein an important therapeutic target, and numerous studies have explored potential therapeutics. Firstly, peptides that block RBD–ACE2-binding derived from both RBD [
<xref rid="B114-viruses-11-00059" ref-type="bibr">114</xref>
] and ACE2 [
<xref rid="B76-viruses-11-00059" ref-type="bibr">76</xref>
] could be developed as novel therapeutics against SARS-CoV infection. Secondly, peptides binding to the S protein interfere with the cleavage of S1 and S2. This step inhibits the production of functional S1 and S2 subunits and the consequent fusion of the viral envelope with the host cell membrane. Thirdly, anti-SARS-CoV peptides blocking the HR1–HR2 interaction by forming a fusion-active core have viral fusion inhibitory activity at the micromolar level [
<xref rid="B115-viruses-11-00059" ref-type="bibr">115</xref>
,
<xref rid="B116-viruses-11-00059" ref-type="bibr">116</xref>
,
<xref rid="B117-viruses-11-00059" ref-type="bibr">117</xref>
]. However, the potential selection of escape mutants with altered host range phenotypes is one of the disadvantages of this strategy that needs further modification [
<xref rid="B118-viruses-11-00059" ref-type="bibr">118</xref>
]. Furthermore, mouse monoclonal antibodies (mAbs) targeting assorted fragments of the SARS-CoV S protein have effectively inhibited SARS-CoV infection [
<xref rid="B79-viruses-11-00059" ref-type="bibr">79</xref>
,
<xref rid="B119-viruses-11-00059" ref-type="bibr">119</xref>
,
<xref rid="B120-viruses-11-00059" ref-type="bibr">120</xref>
,
<xref rid="B121-viruses-11-00059" ref-type="bibr">121</xref>
,
<xref rid="B122-viruses-11-00059" ref-type="bibr">122</xref>
]. A series of neutralizing human mAbs were generated from the B cells of patients infected with SARS-CoV [
<xref rid="B123-viruses-11-00059" ref-type="bibr">123</xref>
,
<xref rid="B124-viruses-11-00059" ref-type="bibr">124</xref>
]. Another strategy used human immunoglobulin transgenic mice immunized with full-length SARS-CoV S proteins [
<xref rid="B125-viruses-11-00059" ref-type="bibr">125</xref>
,
<xref rid="B126-viruses-11-00059" ref-type="bibr">126</xref>
,
<xref rid="B127-viruses-11-00059" ref-type="bibr">127</xref>
]. 80R and CR3014 binding to the ACE2 receptor are examples of S-specific mAbs [
<xref rid="B128-viruses-11-00059" ref-type="bibr">128</xref>
,
<xref rid="B129-viruses-11-00059" ref-type="bibr">129</xref>
].</p>
<p>Similarly, the therapeutic agents that have been developed against MERS-CoV are based on the S protein and basically restrain the binding of receptors or the fusion of membrane proteins, thereby leading to the inhibition of MERS-CoV infection. These methods mainly involve peptidic fusion inhibitors [
<xref rid="B56-viruses-11-00059" ref-type="bibr">56</xref>
,
<xref rid="B63-viruses-11-00059" ref-type="bibr">63</xref>
,
<xref rid="B116-viruses-11-00059" ref-type="bibr">116</xref>
,
<xref rid="B130-viruses-11-00059" ref-type="bibr">130</xref>
], anti-MERS-CoV neutralizing mAbs [
<xref rid="B86-viruses-11-00059" ref-type="bibr">86</xref>
,
<xref rid="B131-viruses-11-00059" ref-type="bibr">131</xref>
], anti-DPP4 mAbs [
<xref rid="B86-viruses-11-00059" ref-type="bibr">86</xref>
,
<xref rid="B132-viruses-11-00059" ref-type="bibr">132</xref>
,
<xref rid="B133-viruses-11-00059" ref-type="bibr">133</xref>
], DPP4 antagonists [
<xref rid="B134-viruses-11-00059" ref-type="bibr">134</xref>
], and protease inhibitors [
<xref rid="B135-viruses-11-00059" ref-type="bibr">135</xref>
,
<xref rid="B136-viruses-11-00059" ref-type="bibr">136</xref>
,
<xref rid="B137-viruses-11-00059" ref-type="bibr">137</xref>
]. However, none of these anti-MERS-CoV curative agents are approved for commercial use in humans.</p>
</sec>
</sec>
<sec id="sec6-viruses-11-00059">
<title>6. The Animal Models of SARS and MERS-CoV</title>
<p>International coordination and cooperation led to the rapid identification of SARS-CoV and MERS-CoV. Emergency control measures and laboratory detection systems which were put in place in response to SARS-CoV and MERS-CoV outbreaks were both exemplary. To establish optimal prevention and control strategies for SARS and MERS, numerous efforts to develop animal models were undertaken in several laboratories, despite the fact that some conflicting results have been reported. It is therefore necessary to compare and document the features and disadvantages of different animal models to better understand viral replication, transmission, pathogenesis, prevention, and treatment. Notably, several animal species were suggested as suitable disease models of SARS-CoV, but most laboratory animals are refractory or only semi-permissive to MERS-CoV infection.</p>
<sec id="sec6dot1-viruses-11-00059">
<title>6.1. Animal Models of SARS-CoV</title>
<p>SARS-CoV replication has been studied in mice, Syrian golden and Chinese hamsters, civet cats, and non-human primates. The most severe symptoms of SARS were observed in aged animals. To develop epidemiological symptoms that advanced age resulted in increased mortality, aged mouse model of SARS-CoV has been generated. Transgenic mice expressing human ACE2 were also developed to closely mimic SARS-CoV infection in humans. Some animal models have been tested and analyzed on the genomic and proteomics level to study the pathogenesis of SARS.</p>
<sec id="sec6dot1dot1-viruses-11-00059">
<title>6.1.1. Mouse Models</title>
<p>Mouse species that have been used as SARS-CoV-infected animal models include BALB/c [
<xref rid="B149-viruses-11-00059" ref-type="bibr">149</xref>
,
<xref rid="B150-viruses-11-00059" ref-type="bibr">150</xref>
], C57BL6 (B6) [
<xref rid="B151-viruses-11-00059" ref-type="bibr">151</xref>
], and 129SvEv-lineage mice. The most relevant transgenic and knockout lines are accessible based on these susceptible animals [
<xref rid="B152-viruses-11-00059" ref-type="bibr">152</xref>
]. Signal transducers and activators of transcription 1 (STAT1)-knockout and myeloid differentiation primary response 88 (MYD88)-knockout mice [
<xref rid="B149-viruses-11-00059" ref-type="bibr">149</xref>
,
<xref rid="B151-viruses-11-00059" ref-type="bibr">151</xref>
,
<xref rid="B153-viruses-11-00059" ref-type="bibr">153</xref>
,
<xref rid="B154-viruses-11-00059" ref-type="bibr">154</xref>
] are examples of mouse models with innate immune deficiency, and such animals display severe effects of the disease, such as pneumonitis, bronchiolitis, and weight loss, and often die within 9 days of infection. Notably, young mice require more mutations and passages than aged mice to produce SARS-CoV mouse-adapted strains. More severe pathological lesions and increased mortality were observed in one-year-old animals, along with fewer mutations at miscellaneous locations throughout the genome [
<xref rid="B98-viruses-11-00059" ref-type="bibr">98</xref>
,
<xref rid="B155-viruses-11-00059" ref-type="bibr">155</xref>
,
<xref rid="B156-viruses-11-00059" ref-type="bibr">156</xref>
,
<xref rid="B157-viruses-11-00059" ref-type="bibr">157</xref>
,
<xref rid="B158-viruses-11-00059" ref-type="bibr">158</xref>
,
<xref rid="B159-viruses-11-00059" ref-type="bibr">159</xref>
]. Intranasal inoculation of four- to eight-week-old BALB/c or B6 mice with SARS-CoV resulted in nasal turbinate in the upper respiratory tract and a high titer of virus replication in the lungs of the lower respiratory tract, and this model was highly reproducible without any signs of morbidity or mortality [
<xref rid="B149-viruses-11-00059" ref-type="bibr">149</xref>
,
<xref rid="B151-viruses-11-00059" ref-type="bibr">151</xref>
]. Neutralizing antibody responses could be generated in sub-lethally infected mice protecting recipients from subsequent lethal challenges, which probably reflected the situation in infected humans during an epidemic [
<xref rid="B160-viruses-11-00059" ref-type="bibr">160</xref>
]. However, on day 2–3 post-infection (pi), virus replication in the respiratory tract peaked but was not accompanied by massive pulmonary inflammation or pneumonitis. By day 5–7 pi, the virus had been eliminated from the lungs [
<xref rid="B149-viruses-11-00059" ref-type="bibr">149</xref>
,
<xref rid="B151-viruses-11-00059" ref-type="bibr">151</xref>
]. It was obvious that viremia is common and long-lasting in patients, while it is rare and transient in mouse models [
<xref rid="B161-viruses-11-00059" ref-type="bibr">161</xref>
]. Mice could therefore be used as a stable and reproducible animal model for the evaluation of vaccines, immune-prophylaxis, and antiviral drugs against SARS-CoV [
<xref rid="B81-viruses-11-00059" ref-type="bibr">81</xref>
,
<xref rid="B96-viruses-11-00059" ref-type="bibr">96</xref>
,
<xref rid="B109-viruses-11-00059" ref-type="bibr">109</xref>
,
<xref rid="B124-viruses-11-00059" ref-type="bibr">124</xref>
,
<xref rid="B149-viruses-11-00059" ref-type="bibr">149</xref>
,
<xref rid="B162-viruses-11-00059" ref-type="bibr">162</xref>
,
<xref rid="B163-viruses-11-00059" ref-type="bibr">163</xref>
,
<xref rid="B164-viruses-11-00059" ref-type="bibr">164</xref>
,
<xref rid="B165-viruses-11-00059" ref-type="bibr">165</xref>
,
<xref rid="B166-viruses-11-00059" ref-type="bibr">166</xref>
].</p>
</sec>
<sec id="sec6dot1dot2-viruses-11-00059">
<title>6.1.2. Hamster Model</title>
<p>Golden Syrian and Chinese hamsters have also been evaluated and shown to be excellent models of SARS-CoV infection, owing to their high titer of virus replication in the respiratory tract, associated with diffuse alveolar damage, interstitial pneumonitis, and pulmonary consolidation [
<xref rid="B104-viruses-11-00059" ref-type="bibr">104</xref>
,
<xref rid="B167-viruses-11-00059" ref-type="bibr">167</xref>
,
<xref rid="B168-viruses-11-00059" ref-type="bibr">168</xref>
,
<xref rid="B169-viruses-11-00059" ref-type="bibr">169</xref>
]. On day 2 pi, peak levels of viral replication were detected in the lower respiratory tract, and the virus was cleared without obvious clinical illness 7–10 days after infection. Similarly to mice, infected hamsters also produced a protective neutralizing-antibody response to subsequent SARS-CoV challenges [
<xref rid="B104-viruses-11-00059" ref-type="bibr">104</xref>
,
<xref rid="B170-viruses-11-00059" ref-type="bibr">170</xref>
]. Resulting from the extremely high titers and reproducible pulmonary pathological lesions in SARS-CoV-infected hamsters, this animal model is ideal for studies on the immunoprophylaxis and treatment of SARS [
<xref rid="B104-viruses-11-00059" ref-type="bibr">104</xref>
,
<xref rid="B170-viruses-11-00059" ref-type="bibr">170</xref>
]. However, there are still limited resources in terms of genetically established animal lines and accurate immunological and cellular biomarkers for hamster models.</p>
</sec>
<sec id="sec6dot1dot3-viruses-11-00059">
<title>6.1.3. Ferret Model</title>
<p>Ferrets were found to be susceptible to SARS-CoV infection [
<xref rid="B171-viruses-11-00059" ref-type="bibr">171</xref>
] but could also transmit the virus at low levels by direct contact [
<xref rid="B84-viruses-11-00059" ref-type="bibr">84</xref>
,
<xref rid="B172-viruses-11-00059" ref-type="bibr">172</xref>
,
<xref rid="B173-viruses-11-00059" ref-type="bibr">173</xref>
,
<xref rid="B174-viruses-11-00059" ref-type="bibr">174</xref>
]. They showed diverse clinical symptoms in different studies [
<xref rid="B171-viruses-11-00059" ref-type="bibr">171</xref>
,
<xref rid="B174-viruses-11-00059" ref-type="bibr">174</xref>
]. Importantly, ferrets could develop fever, which is a characteristic clinical symptom of SARS-CoV-infected patients [
<xref rid="B93-viruses-11-00059" ref-type="bibr">93</xref>
,
<xref rid="B175-viruses-11-00059" ref-type="bibr">175</xref>
]. Similar to rodent models, infection of ferrets with SARS-CoV did not result in significant mortality. However, there are still some conflicting reports regarding the histopathological lesions and severity of clinical observations in the ferret model that require further investigation.</p>
</sec>
<sec id="sec6dot1dot4-viruses-11-00059">
<title>6.1.4. Non-Human Primate Models</title>
<p>Several species of non-human primates (NHP) were evaluated as animal models for SARS. At least six NHP species were tested including three Old World monkeys: rhesus macaques [
<xref rid="B176-viruses-11-00059" ref-type="bibr">176</xref>
,
<xref rid="B177-viruses-11-00059" ref-type="bibr">177</xref>
,
<xref rid="B178-viruses-11-00059" ref-type="bibr">178</xref>
,
<xref rid="B179-viruses-11-00059" ref-type="bibr">179</xref>
,
<xref rid="B180-viruses-11-00059" ref-type="bibr">180</xref>
], cynomolgus macaques [
<xref rid="B177-viruses-11-00059" ref-type="bibr">177</xref>
,
<xref rid="B181-viruses-11-00059" ref-type="bibr">181</xref>
,
<xref rid="B182-viruses-11-00059" ref-type="bibr">182</xref>
], and African green monkeys [
<xref rid="B177-viruses-11-00059" ref-type="bibr">177</xref>
]; and three New World monkeys: the common marmoset [
<xref rid="B183-viruses-11-00059" ref-type="bibr">183</xref>
], squirrel monkeys, and mustached tamarins [
<xref rid="B176-viruses-11-00059" ref-type="bibr">176</xref>
,
<xref rid="B177-viruses-11-00059" ref-type="bibr">177</xref>
,
<xref rid="B178-viruses-11-00059" ref-type="bibr">178</xref>
,
<xref rid="B181-viruses-11-00059" ref-type="bibr">181</xref>
,
<xref rid="B182-viruses-11-00059" ref-type="bibr">182</xref>
,
<xref rid="B183-viruses-11-00059" ref-type="bibr">183</xref>
,
<xref rid="B184-viruses-11-00059" ref-type="bibr">184</xref>
]. Except for squirrel monkeys and mustached tamarins [
<xref rid="B185-viruses-11-00059" ref-type="bibr">185</xref>
], all of the evaluated NHP species facilitated the replication of SARS-CoV [
<xref rid="B186-viruses-11-00059" ref-type="bibr">186</xref>
]. Virus replication was detected in the respiratory tract of rhesus macaques, cynomolgus macaques, and African green monkeys. Pneumonitis was observed in each of these species in different studies [
<xref rid="B176-viruses-11-00059" ref-type="bibr">176</xref>
,
<xref rid="B177-viruses-11-00059" ref-type="bibr">177</xref>
,
<xref rid="B178-viruses-11-00059" ref-type="bibr">178</xref>
,
<xref rid="B182-viruses-11-00059" ref-type="bibr">182</xref>
]. SARS-infected common marmosets displayed a fever, watery diarrhea, pneumonitis, and hepatitis [
<xref rid="B183-viruses-11-00059" ref-type="bibr">183</xref>
]. Unfortunately, research into the clinical signs of disease in cynomolgus and rhesus macaques gave conflicting results and therefore needs further investigation. The main reason for the lack of reproducibility in such studies may be the limited sample size.</p>
</sec>
</sec>
<sec id="sec6dot2-viruses-11-00059">
<title>6.2. Animal Models of MERS-CoV</title>
<p>Small animal models of MERS infection are urgently needed to elucidate MERS pathogenesis and explore potential vaccines and antiviral drugs. Previous studies have demonstrated the difficulties in developing such a model, such as that mice [
<xref rid="B187-viruses-11-00059" ref-type="bibr">187</xref>
,
<xref rid="B188-viruses-11-00059" ref-type="bibr">188</xref>
], ferrets [
<xref rid="B134-viruses-11-00059" ref-type="bibr">134</xref>
], guinea pigs [
<xref rid="B189-viruses-11-00059" ref-type="bibr">189</xref>
], and hamsters [
<xref rid="B189-viruses-11-00059" ref-type="bibr">189</xref>
] are not susceptible to experimental MERS-CoV infection mainly because their homologous DPP4 molecules do not function as receptors for MERS-CoV entry. After administering a high dose of MERS-CoV, no viral replication could be detected in these animals [
<xref rid="B190-viruses-11-00059" ref-type="bibr">190</xref>
]. In an animal model using New Zealand white rabbits, regardless of the fact that detectable viral RNA existed in the respiratory tract and moderate necrosis was observed in nasal turbinates, the animals showed no clinical symptoms of disease [
<xref rid="B191-viruses-11-00059" ref-type="bibr">191</xref>
]. In another study, attempts to infect hamsters with MERS-CoV were not successful [
<xref rid="B192-viruses-11-00059" ref-type="bibr">192</xref>
]. However, despite this, MERS-CoV is a broad host-range virus in vitro [
<xref rid="B25-viruses-11-00059" ref-type="bibr">25</xref>
], and there is hope that a reproducible and stable animal model for human MERS-CoV infection can be improved in the near future.</p>
<sec id="sec6dot2dot1-viruses-11-00059">
<title>6.2.1. Mouse Model for MERS Infection</title>
<p>Despite the fact that wild-type rodents are not susceptible to MERS-CoV infection [
<xref rid="B188-viruses-11-00059" ref-type="bibr">188</xref>
], researchers have developed several models in which mice are susceptible to MERS-CoV infection [
<xref rid="B193-viruses-11-00059" ref-type="bibr">193</xref>
,
<xref rid="B194-viruses-11-00059" ref-type="bibr">194</xref>
,
<xref rid="B195-viruses-11-00059" ref-type="bibr">195</xref>
]. The first mouse model of MERS infection reported in 2014 involved transducing animals with recombinant adenovirus 5 encoding human DPP4 (hDPP4) molecules intranasally, and this resulted in replication of MERS-CoV in the lungs. This mouse model also showed clinical symptoms of interstitial pneumonia, including inflammatory cell infiltration, and thickened alveolar and mild edema [
<xref rid="B195-viruses-11-00059" ref-type="bibr">195</xref>
]. However, there are certain limitations to this model, such as the uncontrolled expression and distribution of hDPP4. In 2015, the establishment of hDPP4 transgenic mice was reported [
<xref rid="B194-viruses-11-00059" ref-type="bibr">194</xref>
]. MERS-CoV could infect this mouse model effectively. However, similarly to SARS-CoV-infected ACE2 transgenic mice [
<xref rid="B196-viruses-11-00059" ref-type="bibr">196</xref>
], systemic expressions led to multiple organ lesions [
<xref rid="B194-viruses-11-00059" ref-type="bibr">194</xref>
], resulting in the death of the animals. Most recently, the homologous hDPP4 gene was used in several MERS transgenic mouse models [
<xref rid="B193-viruses-11-00059" ref-type="bibr">193</xref>
,
<xref rid="B197-viruses-11-00059" ref-type="bibr">197</xref>
]. Remarkably, hDPP4 knockin (KI) mice, where mouse DPP4 gene fragments had been displaced by homologous human DPP4 fragments, showed effective receptor binding. Furthermore, a mouse-adapted MERS-CoV strain (MERS
<sub>MA</sub>
) including 13–22 mutations was produced in the lungs of hDPP4-KI mice after 30 serial passages, causing effective weight loss and mortality in this mouse model [
<xref rid="B193-viruses-11-00059" ref-type="bibr">193</xref>
]. Both this hDPP4-KI mouse and the MERS
<sub>MA</sub>
strain provide better tools to explore the pathogenesis of MERS and potential novel treatments.</p>
</sec>
<sec id="sec6dot2dot2-viruses-11-00059">
<title>6.2.2. Camelidae</title>
<p>As a reservoir of MERS-CoV, dromedary camels showed mild upper respiratory infections after the administration of MERS-CoV [
<xref rid="B198-viruses-11-00059" ref-type="bibr">198</xref>
]. Oronasal infection of MERS-CoV in alpacas, a close relative within the Camelidae family, resulted in an asymptomatic infection with no signs of upper or lower respiratory tract disease [
<xref rid="B199-viruses-11-00059" ref-type="bibr">199</xref>
,
<xref rid="B200-viruses-11-00059" ref-type="bibr">200</xref>
]. Additionally, owing to their high cost and relatively large size, these animal models are not available for high-throughput studies of MERS.</p>
</sec>
<sec id="sec6dot2dot3-viruses-11-00059">
<title>6.2.3. Non-Human Primates</title>
<p>NHPs, such as the rhesus macaques [
<xref rid="B201-viruses-11-00059" ref-type="bibr">201</xref>
] and common marmosets [
<xref rid="B202-viruses-11-00059" ref-type="bibr">202</xref>
], are useful models for studying the pathogenesis of mild MERS-CoV infection and evaluating novel therapies for humans, although the degree of replication and disease severity vary [
<xref rid="B192-viruses-11-00059" ref-type="bibr">192</xref>
,
<xref rid="B201-viruses-11-00059" ref-type="bibr">201</xref>
,
<xref rid="B203-viruses-11-00059" ref-type="bibr">203</xref>
,
<xref rid="B204-viruses-11-00059" ref-type="bibr">204</xref>
]. MERS-CoV caused transient lower respiratory tract infection in rhesus macaques, with associated pneumonia. Clinical signs were observed by day 1 pi and resolved as early as day 4 pi [
<xref rid="B201-viruses-11-00059" ref-type="bibr">201</xref>
]. Relatively mild clinical symptoms were observed early on in infection without fatalities, indicating that rhesus macaques do not recapitulate the severe infections observed in human cases; however, treatment of MERS-CoV-infected rhesus macaques with IFN-α and ribavirin decreased virus replication, alleviated the host response, and improved the clinical outcome [
<xref rid="B205-viruses-11-00059" ref-type="bibr">205</xref>
]. Infection of MERS-CoV in common marmosets demonstrated various extents of damage depending on the study, but successfully reproduced several features of MERS-CoV infection in humans. Importantly, one study indicated that the infection became progressive severe pneumonia [
<xref rid="B203-viruses-11-00059" ref-type="bibr">203</xref>
], while other groups found that MERS-CoV-infected common marmosets only developed mild to moderate nonlethal respiratory diseases by intratracheal administration [
<xref rid="B206-viruses-11-00059" ref-type="bibr">206</xref>
].</p>
</sec>
</sec>
</sec>
<sec id="sec7-viruses-11-00059">
<title>7. Role of Host Receptors in Animal Models of SARS-CoV and MERS-CoV</title>
<p>The reasons for host restriction, none or limited clinical symptoms observed in varies animal models are complexity. The interaction between the host receptor and functional proteins of SARS and MERS, respectively, plays an important and predominant role. In the context of animal models of SARS-CoV infection, researchers have compared the ACE2 amino acids that interact with the S protein RBD from several species. In agreement with the permissive nature of these species, the ACE2 residues of marmoset and hamster are similar to those of hACE2 [
<xref rid="B53-viruses-11-00059" ref-type="bibr">53</xref>
]. By comparison, many residues of mouse ACE2 are different from those of hACE2, and this meets with decreased replication of SARS-CoV in mouse cells [
<xref rid="B207-viruses-11-00059" ref-type="bibr">207</xref>
] and the lungs of young mice [
<xref rid="B149-viruses-11-00059" ref-type="bibr">149</xref>
]. The changes at positions 353 (histidine) and 82 (asparagine) of rat ACE2 relative to hACE2 partially disrupt the S protein-DPP4 interaction and contribute to abrogation of binding. Interestingly, ferrets are permissive to SARS-CoV infection, but most of their ACE2 interaction residues are different from those of hACE2 [
<xref rid="B53-viruses-11-00059" ref-type="bibr">53</xref>
], while many of the ACE2 residues between civet and ferret are the same, which may result in similar affinity [
<xref rid="B208-viruses-11-00059" ref-type="bibr">208</xref>
]. For MERS-CoV, 14 residues of the S protein RBD have direct contact with 15 residues of hDPP4 [
<xref rid="B57-viruses-11-00059" ref-type="bibr">57</xref>
]. Comparisons of human DPP4 binding affinity to that of other species indicated that human DPP4 had the highest affinity to the S protein of MERS-CoV, where the decreasing order of affinity is as follows: human > horses > camels > goats > bats [
<xref rid="B209-viruses-11-00059" ref-type="bibr">209</xref>
]. Further evidence demonstrates that the host restriction of MERS-CoV remarkably depends on the sequence of DPP4, such as the characterization of amino acid residues at the connector of DPP4 with the RBD of S proteins in mice [
<xref rid="B187-viruses-11-00059" ref-type="bibr">187</xref>
,
<xref rid="B210-viruses-11-00059" ref-type="bibr">210</xref>
], hamsters, and cotton rats [
<xref rid="B210-viruses-11-00059" ref-type="bibr">210</xref>
]. However, the multiplicity in severity of disease between rhesus macaques and common marmosets indicate that other host factors can perhaps affect the infection and replication of the virus, such as the presence of S-cleaving proteases [
<xref rid="B187-viruses-11-00059" ref-type="bibr">187</xref>
]. In general, although the structural analysis of receptors-S protein interactions cannot fully explain all the observations for host restriction, they agree with the improved replication in several animal models and that it should be the premier and remarkable focus of small-animal model development. These special residues for host affinity are important to build up transgenic animal models enhancing the permissiveness and infection of SARS and MERS.</p>
</sec>
<sec id="sec8-viruses-11-00059">
<title>8. Outlook and Summary</title>
<p>Unlike SARS-CoV, which resolved without more reported cases, continued outbreaks of MERS-CoV present an ongoing threat to public health. It should be noted that no specific treatment is currently available for HCoVs, and further research into the pathogenesis of HCoV infection is therefore imperative to identify appropriate therapeutic targets. Accordingly, at present, the prevention of viral transmission is of utmost importance to limit the spread of MERS. The enormous ratio of nosocomial infections indicates that preventive measures in hospitals have not been sufficiently implemented. Additionally, as an emerging zoonotic virus, prevention of transmission from dromedary camels is another possibility to reduce the quantity of MERS cases. Regarding clinical therapies, a combination of treatment administered as early as possible and aimed at synchronously disrupting viral replication, inhibiting viral dissemination, and restraining the host response is likely to be most suitable, due to the acute clinical features of MERS with diffuse lung damage and the important role of immunopathology.</p>
<p>Potential treatments must undergo in vitro and in vivo studies to select the most promising options. The development of stable and reproducible animal models of MERS, especially in NHPs, is therefore a decisive step forward. The next step in the development of standardized and controllable therapies against SARS and MERS will be clinical trials in humans, validating a standard protocol for dosage and timing, and accruing data in real time during future outbreaks to monitor specific adverse effects and help inform treatment.</p>
<p>The comprehensive lessons and experiences that have resulted from the outbreaks of SARS and MERS provide valuable insight and advancements in how to react to future emerging and re-emerging infectious agents. Rapid identification of the pathogen via effective diagnostic assays is the first step, followed by the implementation of preventive measures, including raising awareness of the new agent, reporting and recording (suspected) cases, and infection control management in medical facilities. Studies are currently needed that focus on the epidemiology of these organisms, especially in terms of pathogen transmission and potential reservoirs and/or intermediate hosts. Animal models and prophylactic and therapeutic approaches should be promoted, followed by fast-tracked clinical trials.</p>
<p>Our increasing understanding of novel emerging coronaviruses will be accompanied by increasing opportunities for the reasonable design of therapeutics. Importantly, understanding this basic information will not only aid our public health preparedness against SARS-CoV and MERS-CoV, but also help prepare for novel coronaviruses that may emerge.</p>
</sec>
</body>
<back>
<ack>
<title>Acknowledgments</title>
<p>We thank Kate Fox, DPhil, from Liwen Bianji, Edanz Group China (
<uri xlink:href="www.liwenbianji.cn/ac">www.liwenbianji.cn/ac</uri>
), for editing the English text of a draft of this manuscript.</p>
</ack>
<notes>
<title>Funding</title>
<p>This research was funded by CAMS Innovation Fund for Medical Science (CIFMS), grant number 2016-12M-2-006.</p>
</notes>
<notes notes-type="COI-statement">
<title>Conflicts of Interest</title>
<p>The authors declare no conflict of interest.</p>
</notes>
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<floats-group>
<fig id="viruses-11-00059-f001" orientation="portrait" position="float">
<label>Figure 1</label>
<caption>
<p>Schematic representation of the genome organization and functional domains of S protein for SARS-CoV and MERS-CoV. The single-stranded RNA genomes of SARS-CoV and MERS-CoV encode two large genes, the ORF1a and ORF1b genes, which encode 16 non-structural proteins (nsp1–nsp16) that are highly conserved throughout coronaviruses. The structural genes encode the structural proteins, spike (S), envelope (E), membrane (M), and nucleocapsid (N), which are common features to all coronaviruses. The accessory genes (shades of green) are unique to different coronaviruses in terms of number, genomic organization, sequence, and function. The structure of each S protein is shown beneath the genome organization. The S protein mainly contains the S1 and S2 subunits. The residue numbers in each region represent their positions in the S protein of SARS and MERS, respectively. The S1/S2 cleavage sites are highlighted by dotted lines. SARS-CoV, severe acute respiratory syndrome coronavirus; MERS-CoV, Middle East respiratory syndrome coronavirus; CP, cytoplasm domain; FP, fusion peptide; HR, heptad repeat; RBD, receptor-binding domain; RBM, receptor-binding motif; SP, signal peptide; TM, transmembrane domain.</p>
</caption>
<graphic xlink:href="viruses-11-00059-g001"></graphic>
</fig>
<fig id="viruses-11-00059-f002" orientation="portrait" position="float">
<label>Figure 2</label>
<caption>
<p>The life cycle of SARS-CoV and MERS-CoV in host cells. SARS-CoV and MERS-CoV enter target cells through an endosomal pathway. The S proteins of SARS and MERS bind to cellular receptor angiotensin-converting enzyme 2 (ACE2) and cellular receptor dipeptidyl peptidase 4 (DPP4), respectively. Following entry of the virus into the host cell, the viral RNA is unveiled in the cytoplasm. ORF1a and ORF1ab are translated to produce pp1a and pp1ab polyproteins, which are cleaved by the proteases that are encoded by ORF1a to yield 16 non-structural proteins that form the RNA replicase–transcriptase complex. This complex drives the production of negative-sense RNAs [(−) RNA] through both replication and transcription. During replication, full-length (−) RNA copies of the genome are produced and used as templates for full-length (+) RNA genomes. During transcription, a subset of 7–9 sub-genomic RNAs, including those encoding all structural proteins, is produced through discontinuous transcription. Although the different sub-genomic mRNAs may contain several open reading frames (ORFs), only the first ORF (that closest to the 5′ end) is translated. Viral nucleocapsids are assembled from genomic RNA and N protein in the cytoplasm, followed by budding into the lumen of the ERGIC (endoplasmic reticulum (ER)–Golgi intermediate compartment). Virions are then released from the infected cell through exocytosis. SARS-CoV, severe acute respiratory syndrome coronavirus; MERS-CoV, Middle East respiratory syndrome coronavirus; S, spike; E, envelope; M, membrane; N, nucleocapsid.</p>
</caption>
<graphic xlink:href="viruses-11-00059-g002"></graphic>
</fig>
<table-wrap id="viruses-11-00059-t001" orientation="portrait" position="float">
<object-id pub-id-type="pii">viruses-11-00059-t001_Table 1</object-id>
<label>Table 1</label>
<caption>
<p>Epidemiology and biological characteristics of the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV).</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th colspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1"></th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">SARS-CoV</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">MERS-CoV</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Genus</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Beta-CoVs, lineage B</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Beta-CoVs, lineage C</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Possible Natural Reservoir</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Bat</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Bat</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Possible Intermediary Host</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Palm civet</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Dromedary camel</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Origin</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Guangdong province, China</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Arabian Peninsula</td>
</tr>
<tr>
<td rowspan="6" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">
<bold>Clinical Epidemiology</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Total global number reported to WHO</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">More than 8098 people</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">2254 (from 2012 through 16 September 2018)</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Affected countries</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">29</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">27</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Number of deaths</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">916</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">800</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Mortality</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">More than 10%</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">More than 35%</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Transmission region</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Globally</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Regionally</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Transmission patterns</td>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">From animal to human;
<break></break>
from human to human</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>The predominant receptor</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Human angiotensin-converting enzyme 2 (ACE2)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Human dipeptidyl peptidase 4 (DPP4 or CD26)</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Receptor</bold>
<break></break>
<bold>distribution</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Arterial and venous endothelium; arterial smooth muscle; small intestine; respiratory tract epithelium; alveolar monocytes and macrophages</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Respiratory tract epithelium; kidney; small intestine; liver and prostate; activated leukocytes</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Cell line susceptibility</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Respiratory tract;
<break></break>
kidney; liver</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Respiratory tract;
<break></break>
intestinal tract;
<break></break>
genitourinary tract;
<break></break>
liver, kidney,
<break></break>
neurons;
<break></break>
monocyte;
<break></break>
Tlymphocyte; and
<break></break>
histiocytic cell lines</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Viral replication efficiency</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">High</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Higher</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">
<bold>Ability to inhibit IFN production</bold>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Delayed recognition and proinflammatory response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Delayed recognition and proinflammatory response</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap id="viruses-11-00059-t002" orientation="portrait" position="float">
<object-id pub-id-type="pii">viruses-11-00059-t002_Table 2</object-id>
<label>Table 2</label>
<caption>
<p>The genomic characterization of SARS-CoV and MERS-CoV.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th colspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1"></th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">SARS-CoV</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">MERS-CoV</th>
</tr>
</thead>
<tbody>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">Length of nucleotides</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">29,727</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">30,119</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">Open reading frames (ORFs)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">11</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">11</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">Structural protein</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">4</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">4</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">Spike protein (length of amino acids)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">1255</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">1353</td>
</tr>
<tr>
<td rowspan="2" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">S1 subunit</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Receptor-binding domain (RBD)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">318–510</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">367–588</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Receptor-binding motif (RBM)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">424–494</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">484–567</td>
</tr>
<tr>
<td rowspan="2" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">S2 subunit</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Heptad repeat 1 (HR1) domains</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">892–1013</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">984–1104</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Heptad repeat 2 (HR2) domains</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">1145–1195</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">1246–1295</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">Non-structural proteins (NSPs)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">At least 5</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">16</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">Accessory proteins</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">8</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">5</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">A characteristic gene order</td>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">5′-replicase ORF1ab, spike (S), envelope (E), membrane (M), and nucleocapsid (N)-3′</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap id="viruses-11-00059-t003" orientation="portrait" position="float">
<object-id pub-id-type="pii">viruses-11-00059-t003_Table 3</object-id>
<label>Table 3</label>
<caption>
<p>Vaccine strategies of SARS-CoV and MERS-CoV.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th rowspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" colspan="1">Vaccine Strategy</th>
<th rowspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" colspan="1">Process of Production</th>
<th colspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1">References</th>
<th rowspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" colspan="1">Advantages</th>
<th rowspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" colspan="1">Disadvantages</th>
</tr>
<tr>
<th align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">SARS</th>
<th align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">MERS</th>
</tr>
</thead>
<tbody>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inactivated virus vaccines</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Virus particles are inactivated by heat, chemicals, or radiation</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Whole virus, with or without adjuvant (promote an effective immune response against the inactivated pathogen) [
<xref rid="B93-viruses-11-00059" ref-type="bibr">93</xref>
,
<xref rid="B94-viruses-11-00059" ref-type="bibr">94</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Whole virus, with or without adjuvant (promote an effective immune response against the inactivated pathogen) [
<xref rid="B91-viruses-11-00059" ref-type="bibr">91</xref>
,
<xref rid="B95-viruses-11-00059" ref-type="bibr">95</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Maintained virus particles structure; rapidly develop; easy to prepare; safety; high-titer neutralizing antibodies [
<xref rid="B93-viruses-11-00059" ref-type="bibr">93</xref>
]; protection with adjuvant [
<xref rid="B96-viruses-11-00059" ref-type="bibr">96</xref>
,
<xref rid="B97-viruses-11-00059" ref-type="bibr">97</xref>
].</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Potential inappropriate for highly immunosuppressed individuals; possible T
<sub>H</sub>
2 cell-distortive immune response [
<xref rid="B98-viruses-11-00059" ref-type="bibr">98</xref>
,
<xref rid="B99-viruses-11-00059" ref-type="bibr">99</xref>
].</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Live-attenuated virus vaccines</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Attenuated the virulence, but still keeping it viable by mutagenesis or targeted deletions</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Envelope protein deletion [
<xref rid="B100-viruses-11-00059" ref-type="bibr">100</xref>
]; non-structural protein 14 (nsp14) and exonuclease (ExoN) inactivation [
<xref rid="B101-viruses-11-00059" ref-type="bibr">101</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Full-length infectious cDNA clone or mutant viruses [
<xref rid="B102-viruses-11-00059" ref-type="bibr">102</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inexpensive; quick immunity; less adverse effect; activates all phases of the immune system [
<xref rid="B103-viruses-11-00059" ref-type="bibr">103</xref>
]; more durable immunity; more targeted [
<xref rid="B77-viruses-11-00059" ref-type="bibr">77</xref>
].</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Phenotypic or genotypic reversion possible; need sufficient viral replication [
<xref rid="B77-viruses-11-00059" ref-type="bibr">77</xref>
].</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Viral vector vaccines</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Genetically engineered unrelated viral genome with deficient packaging elements for encoding targeted gene</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Spike and nucleocapsid proteins [
<xref rid="B100-viruses-11-00059" ref-type="bibr">100</xref>
,
<xref rid="B104-viruses-11-00059" ref-type="bibr">104</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Spike and nucleocapsid proteins [
<xref rid="B87-viruses-11-00059" ref-type="bibr">87</xref>
,
<xref rid="B88-viruses-11-00059" ref-type="bibr">88</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Safety; stronger and specific cellular and humoral immune responses [
<xref rid="B77-viruses-11-00059" ref-type="bibr">77</xref>
].</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Varies inoculation routes may produce different immune responses [
<xref rid="B96-viruses-11-00059" ref-type="bibr">96</xref>
]; possibly incomplete protection; may fail in aged vaccinees; possible T
<sub>H</sub>
2 cell-distortive immune response [
<xref rid="B105-viruses-11-00059" ref-type="bibr">105</xref>
].</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Subunit vaccines</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Antigenic components inducing the immune system without introducing viral particles, whole or otherwise.</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Spike and nucleocapsid proteins [
<xref rid="B53-viruses-11-00059" ref-type="bibr">53</xref>
,
<xref rid="B59-viruses-11-00059" ref-type="bibr">59</xref>
,
<xref rid="B106-viruses-11-00059" ref-type="bibr">106</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Spike and nucleocapsid proteins [
<xref rid="B85-viruses-11-00059" ref-type="bibr">85</xref>
,
<xref rid="B86-viruses-11-00059" ref-type="bibr">86</xref>
,
<xref rid="B107-viruses-11-00059" ref-type="bibr">107</xref>
,
<xref rid="B108-viruses-11-00059" ref-type="bibr">108</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">High safety; consistent production; can induce cellular and humoral immune responses; high-titer neutralizing antibodies [
<xref rid="B109-viruses-11-00059" ref-type="bibr">109</xref>
].</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Uncertain cost-effectiveness; relatively lower immunogenicity; need appropriate adjuvants [
<xref rid="B77-viruses-11-00059" ref-type="bibr">77</xref>
].</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">DNA vaccines</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Genetically engineered DNA for directly producing an antigen</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Spike and nucleocapsid proteins [
<xref rid="B110-viruses-11-00059" ref-type="bibr">110</xref>
,
<xref rid="B111-viruses-11-00059" ref-type="bibr">111</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Spike and nucleocapsid proteins [
<xref rid="B89-viruses-11-00059" ref-type="bibr">89</xref>
,
<xref rid="B90-viruses-11-00059" ref-type="bibr">90</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Easier to design; high safety; high-titer neutralizing antibodies [
<xref rid="B110-viruses-11-00059" ref-type="bibr">110</xref>
].</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lower immune responses; potential T
<sub>H</sub>
2 cell-distortive immune response results; potential ineffective; possibly delayed-type hypersensitivity [
<xref rid="B112-viruses-11-00059" ref-type="bibr">112</xref>
].</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap id="viruses-11-00059-t004" orientation="portrait" position="float">
<object-id pub-id-type="pii">viruses-11-00059-t004_Table 4</object-id>
<label>Table 4</label>
<caption>
<p>Potential therapeutics for severe acute respiratory syndrome (SARS) and MERS.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th rowspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" colspan="1">Treatment</th>
<th colspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1">Stage of Development</th>
</tr>
<tr>
<th align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">SARS (Notes)</th>
<th align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">MERS (Notes)</th>
</tr>
</thead>
<tbody>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Host protease inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Effective in mouse models [
<xref rid="B138-viruses-11-00059" ref-type="bibr">138</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">In vitro inhibition [
<xref rid="B138-viruses-11-00059" ref-type="bibr">138</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Viral protease inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">In vitro inhibition [
<xref rid="B139-viruses-11-00059" ref-type="bibr">139</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">In vitro inhibition [
<xref rid="B140-viruses-11-00059" ref-type="bibr">140</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Monoclonal and polyclonal antibodies</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Effective in mouse, ferrets, golden Syrian hamster [
<xref rid="B124-viruses-11-00059" ref-type="bibr">124</xref>
,
<xref rid="B141-viruses-11-00059" ref-type="bibr">141</xref>
,
<xref rid="B142-viruses-11-00059" ref-type="bibr">142</xref>
] and non-human primate models [
<xref rid="B143-viruses-11-00059" ref-type="bibr">143</xref>
,
<xref rid="B144-viruses-11-00059" ref-type="bibr">144</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Effective in mouse, rabbit, and non-human primate models [
<xref rid="B10-viruses-11-00059" ref-type="bibr">10</xref>
,
<xref rid="B145-viruses-11-00059" ref-type="bibr">145</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Convalescent plasma</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Off-label use in patients [
<xref rid="B146-viruses-11-00059" ref-type="bibr">146</xref>
,
<xref rid="B147-viruses-11-00059" ref-type="bibr">147</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Effective in a mouse model; clinical trial approved [
<xref rid="B10-viruses-11-00059" ref-type="bibr">10</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Interferons</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Off-label use in patients (often in combination with immunoglobulins or thymosins) [
<xref rid="B146-viruses-11-00059" ref-type="bibr">146</xref>
,
<xref rid="B147-viruses-11-00059" ref-type="bibr">147</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Effective in non-human primate models; off-label use in patients (often in combination with a broad-spectrum antibiotic and oxygen) [
<xref rid="B10-viruses-11-00059" ref-type="bibr">10</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Ribavirin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Off-label use in patients (often in combination with corticosteroids) [
<xref rid="B146-viruses-11-00059" ref-type="bibr">146</xref>
,
<xref rid="B147-viruses-11-00059" ref-type="bibr">147</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Effective in a non-human primate model; off-label use in patients (often in combination with a broad-spectrum antibiotic and oxygen) [
<xref rid="B10-viruses-11-00059" ref-type="bibr">10</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lopinavir and ritonavir</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Off-label use in patients (improved the outcome in combination with ribavirin) [
<xref rid="B146-viruses-11-00059" ref-type="bibr">146</xref>
,
<xref rid="B147-viruses-11-00059" ref-type="bibr">147</xref>
]</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Effective in a non-human primate model; off-label use in patients [
<xref rid="B10-viruses-11-00059" ref-type="bibr">10</xref>
,
<xref rid="B148-viruses-11-00059" ref-type="bibr">148</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<bold>Common Feature</bold>
</td>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">None of these therapeutic agents are approved for commercial use in humans</td>
</tr>
</tbody>
</table>
</table-wrap>
</floats-group>
</pmc>
</record>

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