The SARS-CoV-2 pandemic: remaining uncertainties in our understanding of the epidemiology and transmission dynamics of the virus, and challenges to be overcome.

Great progress has been made over the past 18 months in scientific understanding of the biology, epidemiology and pathogenesis of SARS-CoV-2. Extraordinary advances have been made in vaccine development and the execution of clinical trials of possible therapies. However, uncertainties remain, and this review assesses these in the context of virus transmission, epidemiology, control by social distancing measures and mass vaccination and the effect on all of these on emerging variants. We briefly review the current state of the global pandemic, focussing on what is, and what is not, well understood about the parameters that control viral transmission and make up the constituent parts of the basic reproductive number R 0. Major areas of uncertainty include factors predisposing to asymptomatic infection, the population fraction that is asymptomatic, the infectiousness of asymptomatic compared to symptomatic individuals, the contribution of viral transmission of such individuals and what variables influence this. The duration of immunity post infection and post vaccination is also currently unknown, as is the phenotypic consequences of continual viral evolution and the emergence of many viral variants not just in one location, but globally, given the high connectivity between populations in the modern world. The pattern of spread of new variants is also examined. We review what can be learnt from contact tracing, household studies and whole-genome sequencing, regarding where people acquire infection, and how households are seeded with infection since they constitute a major location for viral transmission. We conclude by discussing the challenges to attaining herd immunity, given the uncertainty in the duration of vaccine-mediated immunity, the threat of continued evolution of the virus as demonstrated by the emergence and rapid spread of the Delta variant, and the logistics of vaccine manufacturing and delivery to achieve universal coverage worldwide. Significantly more support from higher income countries (HIC) is required in low- and middle-income countries over the coming year to ensure the creation of community-wide protection by mass vaccination is a global target, not one just for HIC. Unvaccinated populations create opportunities for viral evolution since the net rate of evolution is directly proportional to the number of cases occurring per unit of time. The unit for assessing success in achieving herd immunity is not any individual country, but the world.

Effect of muscimol and L-NAME in the PVN on the RSNA response to volume expansion in conscious rabbits.

In the present study, we have investigated whether the hypothalamic paraventricular nucleus (PVN) contributed to the reflex reduction in renal sympathetic nerve activity (RSNA) normally elicited by volume expansion in the conscious rabbit. RSNA was monitored after volume expansion (Dextran 70, 2 ml/min for 30 min) in animals microinjected into, and outside, the PVN with muscimol (10 nmol), to acutely inhibit neuronal function. Because nitric oxide within the PVN inhibits RSNA, we also examined the effect of NG-nitro-L-arginine methyl ester (L-NAME; 20 nmol) to block nitric oxide synthase. Compared with vehicle, the reduction in RSNA elicited by volume expansion was abolished by injection of muscimol into the PVN. The effect was specific to the PVN because microinjections of muscimol outside the PVN had no effect on the response. L-NAME microinjected into or outside the PVN had no effect on the RSNA response. The findings suggest that the PVN is essential in the central pathways mediating the renal sympathetic nerve response elicited by elevations in plasma volume but that nitric oxide does not play a major role.

Glutamatergic input in the PVN is important in renal nerve response to elevations in osmolality.

Elevations in plasma osmolality elicit reflex humoral and neural responses. The hypothalamic paraventricular nucleus (PVN) is important in humoral responses. We have investigated whether the PVN contributed to the renal nerve reduction that is normally elicited by increased plasma osmolality in the conscious rabbit. Renal sympathetic nerve activity (RSNA) was monitored after an intravenous infusion of hypertonic saline (1.7 M NaCl, 2 ml/min for 7 min). The responses were examined in animals microinjected with muscimol (10 nmol) into, and outside, the PVN to acutely inhibit neuronal function or with kynurenate (25 nmol) to block glutamate receptors. Compared with vehicle, the maximum reduction in RSNA elicited by hypertonic saline was significantly less with muscimol or kynurenate pretreatment into the PVN. A similar study with kynurenate was also performed in sinoaortically denervated rabbits, and similar effects were observed. The effect was specific to the PVN because microinjections of the drugs outside the PVN had no effect on the response. The findings suggest that excitatory inputs into the PVN may be important in the neural responses elicited by elevations in plasma osmolality.

Role of copper in the relaxant action of S-nitrosothiols in the rat anococcygeus muscle.

1. The effects of copper chelators were investigated on the relaxant actions of the S-nitrosothiols S-nitrosoglutathione (GSNO) and S-nitroso-N-acetyl-d,l-penicillamine (SNAP), the non-S-nitrosothiol nitric oxide (NO) donor sodium nitroprusside (SNP), free radical NO (NO.) and the nitrergic neurotransmitter in rat isolated anococcygeus muscle. 2. Cumulative additions of GSNO (0.01-100 micro mol/L), SNAP (0.001-10 micro mol/L), SNP (0.001-1 micro mol/L) and NO. (0.5-5 micro mol/L) and electrical field stimulation (EFS; 1-5 Hz, 10 s) of nitrergic nerves in preparations precontracted with guanethidine (10-30 micro mol/L) and clonidine (0.01-0.3 micro mol/L) produced concentration-dependent relaxations. 3. The Cu[I] chelator neocuproine (10-30 micro mol/L) produced concentration-dependent inhibitions of the relaxations to GSNO and SNAP. At 30 micro mol/L, neocuprinone had no effect on relaxations to SNP (0.001-1 micro mol/L), NO. (0.5-5 micro mol/L) or EFS (1-5 Hz, 10 s). 4. The Cu[II] chelator cuprizone (30 micro mol/L) slightly and significantly enhanced relaxations to GSNO and NO., but had no effect on relaxations to SNAP, SNP or EFS. 5. In conclusion, the results indicate that Cu[I], but not Cu[II], may be involved in the relaxant actions of GSNO and SNAP in the rat anococcygeus muscle.

Tonic sympathoinhibition arising from the hypothalamic PVN in the conscious rabbit.

In the conscious rabbit muscimol (1-10 nmol/side) was microinjected into the hypothalamic paraventricular nucleus to inhibit neuronal function and the acute changes in mean arterial pressure (MAP), heart rate and renal sympathetic nerve activity (RSNA) were monitored. Muscimol (1 nmol) had no effect on the cardiovascular variables, as was the case with vehicle. However, muscimol (10 nmol) elicited a significant increase in RSNA of 184+/-40% and a reduction in heart rate of 49+/-12 beats/min but no change in MAP. The effect of blocking endogenous glutamatergic inputs with the glutamate antagonist, kynurenate (25 nmol), into the PVN was also examined. Kynurenate elicited an increase in RSNA of 35+/-9% with no significant change in MAP or HR. The results suggest that muscimol inhibits a tonically active inhibitory influence on RSNA arising from the PVN in the conscious rabbit. A glutamatergic input into the PVN appears to contribute to the tonic activation of this inhibitory influence.