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Musa AO, Faber SR, Forrest K, Smith KP, Sengupta S, López CB. Identification of distinct genotypes in circulating RSV A strains based on variants in the virus replication-associated genes. J Virol 2024; 98:e0099024. [PMID: 39007617 PMCID: PMC11334426 DOI: 10.1128/jvi.00990-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/16/2024] [Indexed: 07/16/2024] Open
Abstract
Respiratory syncytial virus (RSV) is a common cause of respiratory infection that often leads to hospitalization of infected younger children and older adults. RSV is classified into two strains, A and B, each with several subgroups or genotypes. One issue with the definition of these subgroups is the lack of a unified method of identification or genotyping. We propose that genotyping strategies based on the genes coding for replication-associated proteins could provide critical information on the replication capacity of the distinct subgroups, while clearly distinguishing genotypes. Here, we analyzed the virus replication-associated genes N, P, M2, and L from de novo assembled RSV A sequences obtained from 31 newly sequenced samples from hospitalized patients in Philadelphia and 78 additional publicly available sequences from different geographic locations within the United States. In-depth analysis and annotation of variants in the replication-associated proteins identified the polymerase protein L as a robust target for genotyping RSV subgroups. Importantly, our analysis revealed non-synonymous variations in L that were consistently accompanied by conserved changes in its co-factor P or the M2-2 protein, suggesting associations and interactions between specific domains of these proteins. Similar associations were seen among sequences of the related human metapneumovirus. These results highlight L as an alternative to other RSV genotyping targets and demonstrate the value of in-depth analyses and annotations of RSV sequences as it can serve as a foundation for subsequent in vitro and clinical studies on the efficiency of the polymerase and fitness of different virus isolates.IMPORTANCEGiven the historical heterogeneity of respiratory syncytial virus (RSV) and the disease it causes, there is a need to understand the properties of the circulating RSV strains each season. This information would benefit from an informative and consensus method of genotyping the virus. Here, we carried out a variant analysis that shows a pattern of specific variations among the replication-associated genes of RSV A across different seasons. Interestingly, these variation patterns, which were also seen in human metapneumovirus sequences, point to previously defined interactions of domains within these genes, suggesting co-variation in the replication-associated genes. Our results also suggest a genotyping strategy that can prove to be particularly important in understanding the genotype-phenotype correlation in the era of RSV vaccination, where selective pressure on the virus to evolve is anticipated. More importantly, the categorization of pneumoviruses based on these patterns may be of prognostic value.
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Affiliation(s)
- Abdulafiz O. Musa
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Women's Infectious Diseases Research, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Sydney R. Faber
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Women's Infectious Diseases Research, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Kaitlyn Forrest
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kenneth P. Smith
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Infectious Disease Diagnostics Laboratory, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shaon Sengupta
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carolina B. López
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Women's Infectious Diseases Research, Washington University School of Medicine, Saint Louis, Missouri, USA
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Pierangeli A, Midulla F, Piralla A, Ferrari G, Nenna R, Pitrolo AMG, Licari A, Marseglia GL, Abruzzese D, Pellegrinelli L, Galli C, Binda S, Cereda D, Fracella M, Oliveto G, Campagna R, Petrarca L, Pariani E, Antonelli G, Baldanti F. Sequence analysis of respiratory syncytial virus cases reveals a novel subgroup -B strain circulating in north-central Italy after pandemic restrictions. J Clin Virol 2024; 173:105681. [PMID: 38733664 DOI: 10.1016/j.jcv.2024.105681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/08/2024] [Accepted: 04/28/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Following the pandemic restrictions, the epidemiology of respiratory syncytial virus (RSV) has changed, leading to intense hospitalization peaks. OBJECTIVES This study, conducted at multiple sites in Italy, aimed to describe the temporal dynamics of two post-COVID-19 RSV epidemics. Additionally, the circulating RSV-A and -B lineages were characterized and compared to those found in 2018 and 2019. STUDY DESIGN Respiratory specimens and data were collected from RSV-positive patients, both inpatients, and outpatients, of all ages at three sites in north-central Italy. To analyze these samples, roughly one-sixth were sequenced in the attachment glycoprotein G gene and subjected to phylogenetic and mutational analyses, including pre-pandemic sequences from north-central Italy. RESULTS The first post-pandemic surge of RSV cases was quite intense, occurring from October 2021 to early January 2022. The subsequent RSV epidemic (from November 2022 to early March 2023) also had a high impact, characterized by a rise in elderly patient cases. Post-pandemic cases of RSV-A were caused by various strains present in Italy prior to COVID-19. In contrast, a distinct RSV-B lineage, which was concurrently spreading in other countries, was identified as the main cause of the surge in 2022-2023 but remained undetected in Italy before the pandemic. CONCLUSIONS This study describes the temporal dynamics of post-pandemic RSV subgroups and uncovers a lineage of RSV-B with high genetic divergence that may have increased the impact of decreased population immunity.
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Affiliation(s)
- Alessandra Pierangeli
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, V.le Porta Tiburtina, 28, 00185 Rome, Italy.
| | - Fabio Midulla
- Department of Pediatrics and Infantile Neuropsychiatry, Sapienza University, V.le Regina Elena, 299, 00161, Rome, Italy
| | - Antonio Piralla
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100 Pavia, Italy
| | - Guglielmo Ferrari
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100 Pavia, Italy
| | - Raffaella Nenna
- Department of Pediatrics and Infantile Neuropsychiatry, Sapienza University, V.le Regina Elena, 299, 00161, Rome, Italy
| | | | - Amelia Licari
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, via S. da Nuova, 65, 27100 Pavia, Italy; Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100 Pavia, Italy
| | - Gian Luigi Marseglia
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, via S. da Nuova, 65, 27100 Pavia, Italy; Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100 Pavia, Italy
| | - Dario Abruzzese
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100 Pavia, Italy
| | - Laura Pellegrinelli
- Department of Biomedical Sciences for Health, University of Milan, via C. Pascal, 36, 20133 Milan, Italy
| | - Cristina Galli
- Department of Biomedical Sciences for Health, University of Milan, via C. Pascal, 36, 20133 Milan, Italy
| | - Sandro Binda
- Department of Biomedical Sciences for Health, University of Milan, via C. Pascal, 36, 20133 Milan, Italy
| | - Danilo Cereda
- DG Welfare, Regione Lombardia, Piazza Città di Lombardia, 1, 20124, Milan, Italy
| | - Matteo Fracella
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, V.le Porta Tiburtina, 28, 00185 Rome, Italy
| | - Giuseppe Oliveto
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, V.le Porta Tiburtina, 28, 00185 Rome, Italy
| | - Roberta Campagna
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, V.le Porta Tiburtina, 28, 00185 Rome, Italy
| | - Laura Petrarca
- Department of Pediatrics and Infantile Neuropsychiatry, Sapienza University, V.le Regina Elena, 299, 00161, Rome, Italy
| | - Elena Pariani
- Department of Biomedical Sciences for Health, University of Milan, via C. Pascal, 36, 20133 Milan, Italy
| | - Guido Antonelli
- Virology Laboratory, Department of Molecular Medicine, Sapienza University, V.le Porta Tiburtina, 28, 00185 Rome, Italy; University Hospital Policlinico Umberto I, Sapienza University, V.le del Policlinico 155, 00161 Rome, Italy
| | - Fausto Baldanti
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Viale C. Golgi, 19, 27100 Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, via S. da Nuova, 65, 27100 Pavia, Italy
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Yunker M, Fall A, Norton JM, Abdullah O, Villafuerte DA, Pekosz A, Klein E, Mostafa HH. Genomic Evolution and Surveillance of Respiratory Syncytial Virus during the 2023-2024 Season. Viruses 2024; 16:1122. [PMID: 39066284 PMCID: PMC11281595 DOI: 10.3390/v16071122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/05/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Respiratory syncytial virus (RSV) is a significant cause of morbidity, particularly in infants. This study describes RSV genomic diversity and disease outcomes during the 2023-2024 season in the Johns Hopkins Hospital System (JHHS). Between August and December 2023, 406 patient samples were sequenced, showing that RSV-B GB5.0.5a was the dominant genotype detected. RSV-A genotype GA2.3.5 was detected less frequently. Metadata analysis of patient data revealed that, although RSV-B was more commonly detected, patients with RSV-A infections were more frequently hospitalized. Analysis of both the G- and F-genes revealed multiple amino acid substitutions in both RSV-A and RSV-B, with some positions within the F-protein that could be associated with evasion of antibody responses. Phylogenetic analysis revealed the genetic diversity of circulating GB5.0.5a and GA2.3.5 genotypes. This study serves as an important baseline for genomic surveillance of RSV within the JHHS and will assist in characterizing the impact of the newly approved RSV vaccines on RSV genomic evolution and the emergence of escape mutations.
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Affiliation(s)
- Madeline Yunker
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Meyer B-121F, 600 N. Wolfe St., Baltimore, MD 21287, USA; (M.Y.); (A.F.); (J.M.N.); (O.A.); (D.A.V.)
| | - Amary Fall
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Meyer B-121F, 600 N. Wolfe St., Baltimore, MD 21287, USA; (M.Y.); (A.F.); (J.M.N.); (O.A.); (D.A.V.)
| | - Julie M. Norton
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Meyer B-121F, 600 N. Wolfe St., Baltimore, MD 21287, USA; (M.Y.); (A.F.); (J.M.N.); (O.A.); (D.A.V.)
| | - Omar Abdullah
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Meyer B-121F, 600 N. Wolfe St., Baltimore, MD 21287, USA; (M.Y.); (A.F.); (J.M.N.); (O.A.); (D.A.V.)
| | - David A. Villafuerte
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Meyer B-121F, 600 N. Wolfe St., Baltimore, MD 21287, USA; (M.Y.); (A.F.); (J.M.N.); (O.A.); (D.A.V.)
| | - Andrew Pekosz
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (A.P.); (E.K.)
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21287, USA
| | - Eili Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA; (A.P.); (E.K.)
- Center for Disease Dynamics, Economics, and Policy, Washington, DC 20005, USA
| | - Heba H. Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, Meyer B-121F, 600 N. Wolfe St., Baltimore, MD 21287, USA; (M.Y.); (A.F.); (J.M.N.); (O.A.); (D.A.V.)
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Mojarrad S, Tavakoli Movaghar N, Edalat F, Letafati A, Kargar Jahromi Z, Moattari A. Epidemiological and phylogenetic assessment of human respiratory syncytial virus among pediatric patients presenting acute respiratory infections in Shiraz, Iran during 2015-2016. IRANIAN JOURNAL OF MICROBIOLOGY 2024; 16:411-420. [PMID: 39005603 PMCID: PMC11245347 DOI: 10.18502/ijm.v16i3.15798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
Background and Objectives The pediatric population worldwide bears a significant morbidity and death burden due to acute respiratory infections (ARIs). Human Orthopneumovirus, sometimes referred to as the Human Respiratory Syncytial Virus (HRSV), is one of the main causes of ARIs in infants. The main goal of this study was to identify the genetic diversity of HRSV strains that were circulating in the Iranian population at a certain time of year. Materials and Methods Two hundred youngsters less than 12 years old with acute respiratory infections had samples taken from their throat and pharynx secretions. Then, external and hemi-nested PCR were employed, using specific primers targeting the G gene region to detect HRSV. Subsequently, nine randomly selected positive samples were subjected to sequencing. The results were then compared with reference strains cataloged in GeneBank, and phylogenetic tree was constructed using Chromes and MEGA7. Results Out of 200 samples, 34 were identified as containing HRSV. Subgroup A was predominant, accounting for 61.76% of cases, followed by subgroup BA (35.29%) and subgroup B (2.94%). Phylogenetic analysis revealed five samples associated with subtype B and four with genotype A. Genomic analysis showed three samples under the GA2 subgroup and one under GA1 for subtype A, and four samples in subgroup BA and one in GB2 for subtype B. Conclusion In this study, subgroup A strains, particularly genotype GA2, exhibited a higher prevalence compared to subgroup B strains during the specific period under investigation, shedding light on the genetic landscape of HRSV in this region.
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Affiliation(s)
- Saber Mojarrad
- Department of Bacteriology & Virology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nahid Tavakoli Movaghar
- Department of Bacteriology & Virology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fahime Edalat
- Department of Bacteriology & Virology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arash Letafati
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Kargar Jahromi
- Department of Bacteriology & Virology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Afagh Moattari
- Department of Bacteriology & Virology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Amjad MN, Wang J, Ashraf MA, Shen B, Din GU, Raza MA, Shoaib M, Yue L, Chen L, Xu H, Dong W, Hu Y. Evolutionary trends of respiratory syncytial viruses: Insights from large-scale surveillance and molecular dynamics of G glycoprotein. Heliyon 2024; 10:e30886. [PMID: 38784562 PMCID: PMC11112325 DOI: 10.1016/j.heliyon.2024.e30886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
Human respiratory syncytial virus (RSV) is an underlying cause of lower respiratory illnesses in children, elderly and immunocompromised adults. RSV contains multiple structural and non-structural proteins with two major glycoproteins that control the initial phase of infection, fusion glycoprotein and the attachment (G) glycoprotein. G protein attaches to the ciliated cells of airways initiating the infection. The hypervariable G protein plays a vital role in evolution of RSV strains. We employed multiple bioinformatics tools on systematically accessed large-scale data to evaluate mutations, evolutionary history, and phylodynamics of RSV. Mutational analysis of central conserved region (CCR) on G protein-coding sequences between 163 and 189 positions revealed frequent mutations at site 178 in human RSV (hRSV) A while arginine to glutamine substitutions at site 180 positions in hRSV B, remained prevalent from 2009 to 2014. Phylogenetic analysis indicates multiple signature mutations within G protein responsible for diversification of clades. The USA and China have highest number of surveillance records, followed by Kenya. Markov Chain Monte Carlo Bayesian skyline plot revealed that RSV A evolved steadily from 1990 to 2000, and rapidly between 2003 and 2005. Evolution of RSV B continued from 2003 to 2022, with a high evolution stage from 2016 to 2020. Throughout evolution, cysteine residues maintained their strict conserved states while CCR has an entropy value of 0.0039(±0.0005). This study concludes the notion that RSV G glycoprotein is continuously evolving while the CCR region of G protein maintains its conserved state providing an opportunity for CCR-specific monoclonal antibodys (mAbs) and inhibitors as potential candidates for immunoprophylaxis.
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Affiliation(s)
- Muhammad Nabeel Amjad
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Jing Wang
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Muhammad Awais Ashraf
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Bei Shen
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
| | - Ghayyas ud Din
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Muhammad Asif Raza
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Muhammad Shoaib
- Key Laboratory of New Animal Drug Project, Gansu Province/Key Laboratory of Veterinary Pharmaceutical Development, Ministry of Agriculture and Rural Affairs, Lanzhou Institute of Husbandry and Pharmaceutical Sciences of CAAS, Lanzhou, 730050, China
| | - Lihuan Yue
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
| | - Lingdie Chen
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Huiting Xu
- Pediatric Department, Nanxiang Branch of Ruijin Hospital, Shanghai, 201802, China
| | - Wei Dong
- Pediatric Department, Nanxiang Branch of Ruijin Hospital, Shanghai, 201802, China
| | - Yihong Hu
- CAS Key Laboratory of Molecular Virology & Immunology, Institutional Center for Shared Technologies and Facilities, Pathogen Discovery and Big Data Platform, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, Yueyang Road 320, Shanghai, 200031, China
- University of Chinese Academy of Sciences, Beijing, China
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Girón-Guzmán I, Cuevas-Ferrando E, Barranquero R, Díaz-Reolid A, Puchades-Colera P, Falcó I, Pérez-Cataluña A, Sánchez G. Urban wastewater-based epidemiology for multi-viral pathogen surveillance in the Valencian region, Spain. WATER RESEARCH 2024; 255:121463. [PMID: 38537489 DOI: 10.1016/j.watres.2024.121463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/28/2024] [Accepted: 03/12/2024] [Indexed: 04/24/2024]
Abstract
Wastewater-based epidemiology (WBE) has lately arised as a promising tool for monitoring and tracking viral pathogens in communities. In this study, we analysed WBE's role as a multi-pathogen surveillance strategy to detect the presence of several viral illness causative agents. Thus, an epidemiological study was conducted from October 2021 to February 2023 to estimate the weekly levels of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), Respiratory Syncytial virus (RSV), and Influenza A virus (IAV) in influent wastewater samples (n = 69). In parallel, a one-year study (October 2021 to October 2022) was performed to assess the presence of pathogenic human enteric viruses. Besides, monitoring of proposed viral fecal contamination indicators crAssphage and Pepper mild mottle virus (PMMoV) was also assessed, along with plaque counting of somatic coliphages. Genetic material of rotavirus (RV), human astrovirus (HAStV), and norovirus genogroup I (GI) and GII was found in almost all samples, while hepatitis A and E viruses (HAV and HEV) only tested positive in 3.77 % and 22.64 % of the samples, respectively. No seasonal patterns were overall found for enteric viruses, although RVs had a peak prevalence in the winter months. All samples tested positive for SARS-CoV-2 RNA, with a mean concentration of 5.43 log genome copies per liter (log GC/L). The tracking of the circulating SARS-CoV-2 variants of concern (VOCs) was performed by both duplex RT-qPCR and next generation sequencing (NGS). Both techniques reliably showed how the dominant VOC transitioned from Delta to Omicron during two weeks in Spain in December 2021. RSV and IAV viruses peaked in winter months with mean concentrations 6.40 and 4.10 log GC/L, respectively. Moreover, the three selected respiratory viruses strongly correlated with reported clinical data when normalised by wastewater physico-chemical parameters and presented weaker correlations when normalising sewage concentration levels with crAssphage or somatic coliphages titers. Finally, predictive models were generated for each respiratory virus, confirming high reliability on WBE data as an early-warning system and communities illness monitoring system. Overall, this study presents WBE as an optimal tool for multi-pathogen tracking reflecting viral circulation and diseases trends within a selected area, its value as a multi-pathogen early-warning tool stands out due to its public health interest.
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Affiliation(s)
- Inés Girón-Guzmán
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain
| | - Enric Cuevas-Ferrando
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain.
| | - Regino Barranquero
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain
| | - Azahara Díaz-Reolid
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain
| | - Pablo Puchades-Colera
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain
| | - Irene Falcó
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain; Department of Microbiology and Ecology, University of Valencia, Valencia, Spain
| | - Alba Pérez-Cataluña
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain
| | - Gloria Sánchez
- Institute of Agrochemistry and Food Technology, IATA-CSIC, Av. Agustín Escardino 7, Paterna, Valencia 46980, Spain.
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7
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Piñana M, González-Sánchez A, Andrés C, Vila J, Creus-Costa A, Prats-Méndez I, Arnedo-Muñoz M, Saubi N, Esperalba J, Rando A, Nadal-Baron P, Quer J, González-López JJ, Soler-Palacín P, Martínez-Urtaza J, Larrosa N, Pumarola T, Antón A. Genomic evolution of human respiratory syncytial virus during a decade (2013-2023): bridging the path to monoclonal antibody surveillance. J Infect 2024; 88:106153. [PMID: 38588960 DOI: 10.1016/j.jinf.2024.106153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/18/2024] [Accepted: 03/29/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES This study investigated the prevalence, genetic diversity, and evolution of human respiratory syncytial virus (HRSV) in Barcelona from 2013 to 2023. METHODS Respiratory specimens from patients with RTI suspicion at Hospital Universitari Vall d'Hebron were collected from October 2013 to May 2023 for laboratory-confirmation of respiratory viruses. Next-generation sequencing was performed in randomly-selected samples with Illumina technology. Phylogenetic analyses of whole genome sequences were performed with BEAST v1.10.4. Signals of selection and evolutionary pressures were inferred by population dynamics and evolutionary analyses. Mutations in major surface proteins were genetic and structurally characterised, emphasizing those within antigenic epitopes. RESULTS Analyzing 139,625 samples, 5.3% were HRSV-positive (3008 HRSV-A, 3882 HRSV-B, 56 HRSV-A and -B, and 495 unsubtyped HRSV), with a higher prevalence observed in the paediatric population. Pandemic-related shifts in seasonal patterns returned to normal in 2022-2023. A total of 198 whole-genome sequences were obtained for HRSV-A (6.6% of the HRSV-A positive samples) belonging to GA2.3.5 lineage. For HRSV-B, 167 samples were sequenced (4.3% of the HRSV-B positive samples), belonging to GB5.0.2, GB5.0.4a and GB5.0.5a. HRSV-B exhibited a higher evolution rate. Post-SARS-CoV-2 pandemic, both subtypes showed increased evolutionary rates and decreased effective population size initially, followed by a sharp increase. Analyses indicated negative selective pressure on HRSV. Mutations in antigenic epitopes, including S276N and M274I in palivizumab-targeted site II, and I206M, Q209R, and S211N in nirsevimab-targeted site Ø, were identified. DISCUSSION Particularly in the context of the large-scale use in 2023-2024 season of nirsevimab, continuous epidemiological and genomic surveillance is crucial.
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Affiliation(s)
- Maria Piñana
- Respiratory Viruses Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
| | - Alejandra González-Sánchez
- Respiratory Viruses Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Department of Genetics and Microbiology, School of Biosciences, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Cristina Andrés
- Respiratory Viruses Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Jorgina Vila
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Children's Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain; Infection and Immunity Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Catalonia, Spain; Paediatric Hospitalization Unit, Children's Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Anna Creus-Costa
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Children's Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain
| | - Ignasi Prats-Méndez
- Respiratory Viruses Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Arnedo-Muñoz
- Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Narcís Saubi
- Respiratory Viruses Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Juliana Esperalba
- Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ariadna Rando
- Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Patricia Nadal-Baron
- Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep Quer
- Liver Diseases-Viral Hepatitis, Liver Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain; Biochemistry and Molecular Biology Department, Universitat Autònoma de Barcelona (UAB), Campus de la UAB, Plaça Cívica, 08193 Bellaterra, Spain
| | - Juan José González-López
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pere Soler-Palacín
- Infection and Immunity Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Catalonia, Spain; Paediatric Hospitalization Unit, Children's Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia, Spain; Department of Paediatrics, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Jaime Martínez-Urtaza
- Department of Genetics and Microbiology, School of Biosciences, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Nieves Larrosa
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tomàs Pumarola
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrés Antón
- Respiratory Viruses Unit, Microbiology Department, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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8
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Musa AO, Faber SR, Forrest K, Smith KP, Sengupta S, López CB. Identification of distinct genotypes in circulating RSV A strains based on variants on the virus replication-associated genes. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.22.590570. [PMID: 38712045 PMCID: PMC11071361 DOI: 10.1101/2024.04.22.590570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Respiratory syncytial virus is a common cause of respiratory infection that often leads to hospitalization of infected younger children and older adults. RSV is classified into two strains, A and B, each with several subgroups or genotypes. One issue with the definition of these subgroups is the lack of a unified method of identification or genotyping. We propose that genotyping strategies based on the genes coding for replication-associated proteins could provide critical information on the replication capacity of the distinct subgroup, while clearly distinguishing genotypes. Here, we analyzed the virus replication-associated genes N, P, M2, and L from de novo assembled RSV A sequences obtained from 31 newly sequenced samples from hospitalized patients in Philadelphia and 78 additional publicly available sequences from different geographic locations within the US. In-depth analysis and annotation of the protein variants in L and the other replication-associated proteins N, P, M2-1, and M2-2 identified the polymerase protein L as a robust target for genotyping RSV subgroups. Importantly, our analysis revealed non-synonymous variations in L that were consistently accompanied by conserved changes in its co-factor P or the M2-2 protein, suggesting associations and interactions between specific domains of these proteins. These results highlight L as an alternative to other RSV genotyping targets and demonstrate the value of in-depth analyses and annotations of RSV sequences as it can serve as a foundation for subsequent in vitro and clinical studies on the efficiency of the polymerase and fitness of different virus isolates.
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Affiliation(s)
- Abdulafiz O. Musa
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Womeńs Infectious Diseases Research, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Sydney R. Faber
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Womeńs Infectious Diseases Research, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Kaitlyn Forrest
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kenneth P. Smith
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Infectious Disease Diagnostics Laboratory, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shaon Sengupta
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carolina B. López
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, Missouri, USA
- Center for Womeńs Infectious Diseases Research, Washington University School of Medicine, Saint Louis, Missouri, USA
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9
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Rios-Guzman E, Simons LM, Dean TJ, Agnes F, Pawlowski A, Alisoltanidehkordi A, Nam HH, Ison MG, Ozer EA, Lorenzo-Redondo R, Hultquist JF. Deviations in RSV epidemiological patterns and population structures in the United States following the COVID-19 pandemic. Nat Commun 2024; 15:3374. [PMID: 38643200 PMCID: PMC11032338 DOI: 10.1038/s41467-024-47757-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/11/2024] [Indexed: 04/22/2024] Open
Abstract
Respiratory Syncytial Virus (RSV) is a leading cause of acute respiratory tract infection, with the greatest impact on infants, immunocompromised individuals, and older adults. RSV prevalence decreased substantially in the United States (US) following the implementation of COVID-19-related non-pharmaceutical interventions but later rebounded with abnormal seasonality. The biological and epidemiological factors underlying this altered behavior remain poorly defined. In this retrospective cohort study from 2009 to 2023 in Chicago, Illinois, US, we examined RSV epidemiology, clinical severity, and genetic diversity. We found that changes in RSV diagnostic platforms drove increased detections in outpatient settings post-2020 and that hospitalized adults infected with RSV-A were at higher risk of intensive care admission than those with RSV-B. While population structures of RSV-A remained unchanged, RSV-B exhibited a genetic shift into geographically distinct clusters. Mutations in the antigenic regions of the fusion protein suggest convergent evolution with potential implications for vaccine and therapeutic development.
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Affiliation(s)
- Estefany Rios-Guzman
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA
| | - Lacy M Simons
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA
| | - Taylor J Dean
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA
| | - Francesca Agnes
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA
| | - Anna Pawlowski
- Northwestern Medicine Enterprise Data Warehouse, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Arghavan Alisoltanidehkordi
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA
| | - Hannah H Nam
- Department of Infectious Diseases, University of California - Irvine, Orange, CA, 92868, USA
| | - Michael G Ison
- Division of Microbiology and Infectious Diseases (DMID), National Institute of Health, Rockville, MD, 20852, USA
| | - Egon A Ozer
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA
| | - Ramon Lorenzo-Redondo
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA
| | - Judd F Hultquist
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
- Center for Pathogen Genomics and Microbial Evolution, Northwestern University Havey Institute for Global Health, Chicago, IL, 60611, USA.
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10
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Riccò M, Parisi S, Corrado S, Marchesi F, Bottazzoli M, Gori D. Respiratory Syncytial Virus Infections in Recipients of Bone Marrow Transplants: A Systematic Review and Meta-Analysis. Infect Dis Rep 2024; 16:317-355. [PMID: 38667752 PMCID: PMC11050314 DOI: 10.3390/idr16020026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Human Respiratory Syncytial Virus (RSV) is a common cause of respiratory tract infections. Usually associated with infants and children, an increasing amount of evidence suggests that RSV can cause substantial morbidity and mortality in immunocompromised individuals, including recipients of bone marrow transplantation (BMT). The present systematic review was therefore designed in accordance with the PRISMA guidelines to collect available evidence about RSV infections in BMT recipients. Three medical databases (PubMed, Embase, and MedRxiv) were therefore searched for eligible observational studies published up to 30 September 2023 and collected cases were pooled in a random-effects model. Heterogeneity was assessed using I2 statistics. Reporting bias was assessed by means of funnel plots and regression analysis. Overall, 30 studies were retrieved, including 20,067 BMT cases and 821 RSV infection episodes. Of them, 351 were lower respiratory tract infections, and a total of 78 RSV-related deaths were collected. A pooled attack rate of 5.40% (95% confidence interval [95%CI] 3.81 to 7.60) was identified, with a corresponding incidence rate of 14.77 cases per 1000 person-years (95%CI 9.43 to 20.11), and a case fatality ratio (CFR) of 7.28% (95%CI 4.94 to 10.60). Attack rates were higher in adults (8.49%, 95%CI 5.16 to 13.67) than in children (4.79%, 95%CI 3.05 to 7.45), with similar CFR (5.99%, 95%CI 2.31 to 14.63 vs. 5.85%, 95%CI 3.35 to 10.02). By assuming RSV attack rates as a reference group, influenza (RR 0.518; 95%CI 0.446 to 0.601), adenovirus (RR 0.679, 95%CI 0.553 to 0.830), and human metapneumovirus (RR 0.536, 95%CI 0.438 to 0.655) were associated with a substantially reduced risk for developing corresponding respiratory infection. Despite the heterogeneous settings and the uneven proportion of adult and pediatric cases, our study has identified high attack rates and a substantial CFR of RSV in recipients of BMT, stressing the importance of specifically tailored preventive strategies and the need for effective treatment options.
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Affiliation(s)
- Matteo Riccò
- AUSL–IRCCS di Reggio Emilia, Servizio di Prevenzione e Sicurezza Negli Ambienti di Lavoro (SPSAL), Local Health Unit of Reggio Emilia, 42122 Reggio Emilia, Italy
| | | | - Silvia Corrado
- ASST Rhodense, Dipartimento della donna e Area Materno-Infantile, UOC Pediatria, 20024 Milan, Italy;
| | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Marco Bottazzoli
- Department of Otorhinolaryngology, APSS Trento, 38122 Trento, Italy
| | - Davide Gori
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy
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11
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Hultquist J, Rios-Guzman E, Simons L, Dean T, Agnes F, Pawlowski A, Alisoltanidehkordi A, Nam H, Ison M, Ozer E, Lorenzo-Redondo R. Altered RSV Epidemiology and Genetic Diversity Following the COVID-19 Pandemic. RESEARCH SQUARE 2023:rs.3.rs-3712859. [PMID: 38168164 PMCID: PMC10760306 DOI: 10.21203/rs.3.rs-3712859/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Respiratory Syncytial Virus (RSV) is a leading cause of acute respiratory tract infection, with greatest impact on infants, immunocompromised individuals, and older adults. RSV prevalence decreased substantially following the implementation of non-pharmaceutical interventions to mitigate the COVID-19 pandemic but later rebounded with initially abnormal seasonality. The biological and epidemiological factors underlying this altered behavior remain poorly defined. In this retrospective cohort study, we examined RSV epidemiology, clinical severity, and genetic diversity in the years surrounding the COVID-19 pandemic. We found that changes in RSV diagnostic platforms drove increased detections in outpatient settings after 2020 and that hospitalized adults with RSV-A were at higher risk of needing intensive care than those with RSV-B. While the population structure of RSV-A remained unchanged, the population structure of RSV-B shifted in geographically distinct clusters. Mutations in the antigenic regions of the fusion protein suggest convergent evolution with potential implications for vaccine and therapeutic development.
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12
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Pronyk PM, de Alwis R, Rockett R, Basile K, Boucher YF, Pang V, Sessions O, Getchell M, Golubchik T, Lam C, Lin R, Mak TM, Marais B, Twee-Hee Ong R, Clapham HE, Wang L, Cahyorini Y, Polotan FGM, Rukminiati Y, Sim E, Suster C, Smith GJD, Sintchenko V. Advancing pathogen genomics in resource-limited settings. CELL GENOMICS 2023; 3:100443. [PMID: 38116115 PMCID: PMC10726422 DOI: 10.1016/j.xgen.2023.100443] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Genomic sequencing has emerged as a powerful tool to enhance early pathogen detection and characterization with implications for public health and clinical decision making. Although widely available in developed countries, the application of pathogen genomics among low-resource, high-disease burden settings remains at an early stage. In these contexts, tailored approaches for integrating pathogen genomics within infectious disease control programs will be essential to optimize cost efficiency and public health impact. We propose a framework for embedding pathogen genomics within national surveillance plans across a spectrum of surveillance and laboratory capacities. We adopt a public health approach to genomics and examine its application to high-priority diseases relevant in resource-limited settings. For each grouping, we assess the value proposition for genomics to inform public health and clinical decision-making, alongside its contribution toward research and development of novel diagnostics, therapeutics, and vaccines.
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Affiliation(s)
- Paul Michael Pronyk
- Centre for Outbreak Preparedness, Duke-NUS Medical School, Singapore 169857, Singapore.
| | - Ruklanthi de Alwis
- Centre for Outbreak Preparedness, Duke-NUS Medical School, Singapore 169857, Singapore; Emerging Infectious Diseases Programme, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Rebecca Rockett
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia; Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Kerri Basile
- Centre for Infectious Diseases and Microbiology Laboratory Services, NSW Health Pathology - Institute of Clinical Pathology and Medical Research, Westmead, NSW 2145, Australia
| | - Yann Felix Boucher
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore; Infectious Diseases Translational Research Programme, Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore 117549, Singapore; Singapore Centre for Environmental Life Sciences Engineering, National University of Singapore, Singapore 117549, Singapore; Nanyang Technological University, Singapore 639798, Singapore
| | - Vincent Pang
- Centre for Outbreak Preparedness, Duke-NUS Medical School, Singapore 169857, Singapore
| | - October Sessions
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Marya Getchell
- Centre for Outbreak Preparedness, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Tanya Golubchik
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia; Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Westmead, NSW 2145, Australia; Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LF, UK
| | - Connie Lam
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia; Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Raymond Lin
- National Public Health Laboratory, National Centre for Infectious Diseases, Singapore 308442, Singapore
| | - Tze-Minn Mak
- Bioinformatics Institute, Agency for Science, Technology and Research, Singapore 138671, Singapore
| | - Ben Marais
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia
| | - Rick Twee-Hee Ong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore
| | - Hannah Eleanor Clapham
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore
| | - Linfa Wang
- Emerging Infectious Diseases Programme, Duke-NUS Medical School, Singapore 169857, Singapore; Programme for Research in Epidemic Preparedness and Response (PREPARE), Ministry of Health, Singapore 169854, Singapore
| | - Yorin Cahyorini
- Center for Health Resilience and Resource Policy, Ministry of Health, Jakarta 12950, Indonesia
| | - Francisco Gerardo M Polotan
- Molecular Biology Laboratory, Research Institute for Tropical Medicine, Muntinlupa 1781, Metro Manila, Philippines
| | - Yuni Rukminiati
- Center for Health Resilience and Resource Policy, Ministry of Health, Jakarta 12950, Indonesia
| | - Eby Sim
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia; Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Carl Suster
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia; Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Gavin J D Smith
- Emerging Infectious Diseases Programme, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Vitali Sintchenko
- Sydney Infectious Diseases Institute, The University of Sydney, Camperdown, NSW 2006, Australia; Centre for Infectious Diseases and Microbiology - Public Health, Westmead Hospital, Westmead, NSW 2145, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, NSW Health Pathology - Institute of Clinical Pathology and Medical Research, Westmead, NSW 2145, Australia
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13
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Ruckwardt TJ. The road to approved vaccines for respiratory syncytial virus. NPJ Vaccines 2023; 8:138. [PMID: 37749081 PMCID: PMC10519952 DOI: 10.1038/s41541-023-00734-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023] Open
Abstract
After decades of work, several interventions to prevent severe respiratory syncytial virus (RSV) disease in high-risk infant and older adult populations have finally been approved. There were many setbacks along the road to victory. In this review, I will discuss the impact of RSV on human health and how structure-based vaccine design set the stage for numerous RSV countermeasures to advance through late phase clinical evaluation. While there are still many RSV countermeasures in preclinical and early-stage clinical trials, this review will focus on products yielding long-awaited efficacy results. Finally, I will discuss some challenges and next steps needed to declare a global victory against RSV.
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Affiliation(s)
- Tracy J Ruckwardt
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, 20892, USA.
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14
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Sacconnay L, De Smedt J, Rocha-Perugini V, Ong E, Mascolo R, Atas A, Vanden Abeele C, de Heusch M, De Schrevel N, David MP, Bouzya B, Stobbelaar K, Vanloubbeeck Y, Delputte PL, Mallett CP, Dezutter N, Warter L. The RSVPreF3-AS01 vaccine elicits broad neutralization of contemporary and antigenically distant respiratory syncytial virus strains. Sci Transl Med 2023; 15:eadg6050. [PMID: 37611082 DOI: 10.1126/scitranslmed.adg6050] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 07/25/2023] [Indexed: 08/25/2023]
Abstract
The RSVPreF3-AS01 vaccine, containing the respiratory syncytial virus (RSV) prefusion F protein and the AS01 adjuvant, was previously shown to boost neutralization responses against historical RSV strains and to be efficacious in preventing RSV-associated lower respiratory tract diseases in older adults. Although RSV F is highly conserved, variation does exist between strains. Here, we characterized variations in the major viral antigenic sites among contemporary RSV sequences when compared with RSVPreF3 and showed that, in older adults, RSVPreF3-AS01 broadly boosts neutralization responses against currently dominant and antigenically distant RSV strains. RSV-neutralizing responses are thought to play a central role in preventing RSV infection. Therefore, the breadth of RSVPreF3-AS01-elicited neutralization responses may contribute to vaccine efficacy against contemporary RSV strains and those that may emerge in the future.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Kim Stobbelaar
- Department of Biomedical Sciences and Infla-Med Centre of Excellence, University of Antwerp, 2610 Wilrijk, Belgium
| | | | - Peter L Delputte
- Department of Biomedical Sciences and Infla-Med Centre of Excellence, University of Antwerp, 2610 Wilrijk, Belgium
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15
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Xie E, Ahmad S, Smyth RP, Sieben C. Advanced fluorescence microscopy in respiratory virus cell biology. Adv Virus Res 2023; 116:123-172. [PMID: 37524480 DOI: 10.1016/bs.aivir.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Respiratory viruses are a major public health burden across all age groups around the globe, and are associated with high morbidity and mortality rates. They can be transmitted by multiple routes, including physical contact or droplets and aerosols, resulting in efficient spreading within the human population. Investigations of the cell biology of virus replication are thus of utmost importance to gain a better understanding of virus-induced pathogenicity and the development of antiviral countermeasures. Light and fluorescence microscopy techniques have revolutionized investigations of the cell biology of virus infection by allowing the study of the localization and dynamics of viral or cellular components directly in infected cells. Advanced microscopy including high- and super-resolution microscopy techniques available today can visualize biological processes at the single-virus and even single-molecule level, thus opening a unique view on virus infection. We will highlight how fluorescence microscopy has supported investigations on virus cell biology by focusing on three major respiratory viruses: respiratory syncytial virus (RSV), Influenza A virus (IAV) and SARS-CoV-2. We will review our current knowledge of virus replication and highlight how fluorescence microscopy has helped to improve our state of understanding. We will start by introducing major imaging and labeling modalities and conclude the chapter with a perspective discussion on remaining challenges and potential opportunities.
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Affiliation(s)
- Enyu Xie
- Nanoscale Infection Biology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Shazeb Ahmad
- Helmholtz Institute for RNA-based Infection Research, Helmholtz Centre for Infection Research, Würzburg, Germany
| | - Redmond P Smyth
- Helmholtz Institute for RNA-based Infection Research, Helmholtz Centre for Infection Research, Würzburg, Germany; Faculty of Medicine, University of Würzburg, Würzburg, Germany
| | - Christian Sieben
- Nanoscale Infection Biology, Helmholtz Centre for Infection Research, Braunschweig, Germany; Institute of Genetics, Technische Universität Braunschweig, Braunschweig, Germany.
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16
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Percze K, Tolnai ZJ, Eleveld M, Ou L, Du H, Olia AS, Kwong PD, de Jonge MI, Mészáros T. Tryptophan-like side chain holding aptamers inhibit respiratory syncytial virus infection of lung epithelial cells. Sci Rep 2023; 13:9403. [PMID: 37296186 PMCID: PMC10251311 DOI: 10.1038/s41598-023-36428-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Respiratory syncytial virus (RSV) is a leading cause of serious and even fatal acute lower respiratory tract infections in infants and in the elderly. Potent RSV neutralization has been achieved by antibodies that selectively bind the prefusion form of the viral fusion (F) protein. We hypothesised that similar potent neutralization could be achieved using F protein targeting aptamers. Aptamers have yet to reach their translational potential for therapeutics or diagnostics due to their short half-life and limited range of target-aptamer interactions; these shortcomings can, however, be ameliorated by application of amino acid-like side chain holding nucleotides. In this study, a stabilized version of the prefusion RSV F protein was targeted by aptamer selection using an oligonucleotide library holding a tryptophan-like side chain. This process resulted in aptamers that bound the F protein with high affinity and differentiated between its pre- and postfusion conformation. Identified aptamers inhibited viral infection of lung epithelial cells. Moreover, introduction of modified nucleotides extended aptamer half-lives. Our results suggest that targeting aptamers to the surface of viruses could yield effective drug candidates, which could keep pace with the continuously evolving pathogens.
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Affiliation(s)
- Krisztina Percze
- Department of Molecular Biology, Institute of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Zoltán János Tolnai
- Department of Molecular Biology, Institute of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Marc Eleveld
- Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Li Ou
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Haijuan Du
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Adam S Olia
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Peter D Kwong
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Marien I de Jonge
- Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tamás Mészáros
- Department of Molecular Biology, Institute of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary.
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Panatto D, Domnich A, Lai PL, Ogliastro M, Bruzzone B, Galli C, Stefanelli F, Pariani E, Orsi A, Icardi G. Epidemiology and molecular characteristics of respiratory syncytial virus (RSV) among italian community-dwelling adults, 2021/22 season. BMC Infect Dis 2023; 23:134. [PMID: 36882698 PMCID: PMC9990006 DOI: 10.1186/s12879-023-08100-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/20/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is a leading cause of acute respiratory infections worldwide. While historically RSV research has been focused on children, data on RSV infection in adults are limited. The goal of this study was to establish the prevalence of RSV in community-dwelling Italian adults and analyze its genetic variability during the 2021/22 winter season. METHODS In this cross-sectional study, a random sample of naso-/oropharyngeal specimens from symptomatic adults seeking for SARS-CoV-2 molecular testing between December 2021 and March 2022 were tested for RSV and other respiratory pathogens by means of reverse-transcription polymerase chain reaction. RSV-positive samples were further molecularly characterized by sequence analysis. RESULTS Of 1,213 samples tested, 1.6% (95% CI: 0.9-2.4%) were positive for RSV and subgroups A (44.4%) and B (55.6%) were identified in similar proportions. The epidemic peak occurred in December 2021, when the RSV prevalence was as high as 4.6% (95% CI: 2.2-8.3%). The prevalence of RSV detection was similar (p = 0.64) to that of influenza virus (1.9%). All RSV A and B strains belonged to the ON1 and BA genotypes, respectively. Most (72.2%) RSV-positive samples were also positive for other pathogens being SARS-CoV-2, Streptococcus pneumoniae and rhinovirus the most frequent. RSV load was significantly higher among mono-detections than co-detections. CONCLUSION During the 2021/22 winter season, characterized by the predominant circulation of SARS-CoV-2 and some non-pharmaceutical containment measures still in place, a substantial proportion of Italian adults tested positive for genetically diversified strains of both RSV subtypes. In view of the upcoming registration of vaccines, establishment of the National RSV surveillance system is urgently needed.
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Affiliation(s)
- Donatella Panatto
- Department of Health Sciences, University of Genoa, Via A. Pastore, 1, 16132, Genoa, Italy. .,Interuniversity Research Center on Influenza and Other Transmissible Infections (CIRI-IT), Genoa, Italy.
| | - Alexander Domnich
- Hygiene Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Piero Luigi Lai
- Department of Health Sciences, University of Genoa, Via A. Pastore, 1, 16132, Genoa, Italy
| | - Matilde Ogliastro
- Department of Health Sciences, University of Genoa, Via A. Pastore, 1, 16132, Genoa, Italy
| | - Bianca Bruzzone
- Hygiene Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Cristina Galli
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Federica Stefanelli
- Hygiene Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Elena Pariani
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Andrea Orsi
- Department of Health Sciences, University of Genoa, Via A. Pastore, 1, 16132, Genoa, Italy.,Interuniversity Research Center on Influenza and Other Transmissible Infections (CIRI-IT), Genoa, Italy.,Hygiene Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Giancarlo Icardi
- Department of Health Sciences, University of Genoa, Via A. Pastore, 1, 16132, Genoa, Italy.,Interuniversity Research Center on Influenza and Other Transmissible Infections (CIRI-IT), Genoa, Italy.,Hygiene Unit, San Martino Policlinico Hospital-IRCCS for Oncology and Neurosciences, Genoa, Italy
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18
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Bergeron HC, Tripp RA. RSV Replication, Transmission, and Disease Are Influenced by the RSV G Protein. Viruses 2022; 14:v14112396. [PMID: 36366494 PMCID: PMC9692685 DOI: 10.3390/v14112396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/24/2022] [Accepted: 10/28/2022] [Indexed: 01/31/2023] Open
Abstract
It is important to understand the features affecting virus replication, fitness, and transmissibility as they contribute to the outcome of infection and affect disease intervention approaches. Respiratory syncytial virus (RSV) is a major contributor to respiratory disease, particularly in the infant and elderly populations. Although first described over 60 years ago, there are no approved vaccines and there are limited specific antiviral treatments due in part to our incomplete understanding of the features affecting RSV replication, immunity, and disease. RSV studies have typically focused on using continuous cell lines and conventional RSV strains to establish vaccine development and various antiviral countermeasures. This review outlines how the RSV G protein influences viral features, including replication, transmission, and disease, and how understanding the role of the G protein can improve the understanding of preclinical studies.
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Esposito S, Abu Raya B, Baraldi E, Flanagan K, Martinon Torres F, Tsolia M, Zielen S. RSV Prevention in All Infants: Which Is the Most Preferable Strategy? Front Immunol 2022; 13:880368. [PMID: 35572550 PMCID: PMC9096079 DOI: 10.3389/fimmu.2022.880368] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022] Open
Abstract
Respiratory syncytial virus (RSV) causes a spectrum of respiratory illnesses in infants and young children that may lead to hospitalizations and a substantial number of outpatient visits, which result in a huge economic and healthcare burden. Most hospitalizations happen in otherwise healthy infants, highlighting the need to protect all infants against RSV. Moreover, there is evidence on the association between early-life RSV respiratory illness and recurrent wheezing/asthma-like symptoms As such, RSV is considered a global health priority. However, despite this, the only prevention strategy currently available is palivizumab, a monoclonal antibody (mAb) indicated in a subset of preterm infants or those with comorbidities, hence leaving the majority of the infant population unprotected against this virus. Therefore, development of prevention strategies against RSV for all infants entering their first RSV season constitutes a large unmet medical need. The aim of this review is to explore different immunization approaches to protect all infants against RSV. Prevention strategies include maternal immunization, immunization of infants with vaccines, immunization of infants with licensed mAbs (palivizumab), and immunization of infants with long-acting mAbs (e.g., nirsevimab, MK-1654). Of these, palivizumab use is restricted to a small population of infants and does not offer a solution for all-infant protection, whereas vaccine development in infants has encountered various challenges, including the immaturity of the infant immune system, highlighting that future pediatric vaccines will most likely be used in older infants (>6 months of age) and children. Consequently, maternal immunization and immunization of infants with long-acting mAbs represent the two feasible strategies for protection of all infants against RSV. Here, we present considerations regarding these two strategies covering key areas which include mechanism of action, "consistency" of protection, RSV variability, duration of protection, flexibility and optimal timing of immunization, benefit for the mother, programmatic implementation, and acceptance of each strategy by key stakeholders. We conclude that, based on current data, immunization of infants with long-acting mAbs might represent the most effective approach for protecting all infants entering their first RSV season.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, Parma, Italy
| | - Bahaa Abu Raya
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman’s and Child’s Health, Padova University Hospital, Padova, Italy
| | - Katie Flanagan
- School of Medicine, Faculty of Health Sciences, University of Tasmania, Launceston, TAS, Australia
- School of Health and Biomedical Science, RMIT University, Melbourne, VIC, Australia
- Department of Immunology and Pathology, Monash University, Melbourne, VIC, Australia
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, TAS, Australia
| | - Federico Martinon Torres
- Genetics, Vaccines, Infections and Pediatrics Research group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Maria Tsolia
- Second Department of Pediatrics, National and Kapodistrian University of Athens, “A&P Kyriakou” Children’s Hospital, Athens, Greece
| | - Stefan Zielen
- Department for Children and Adolescents, Division of Allergology, Pulmonology and Cystic Fibrosis, Goethe-University Hospital, Frankfurt am Main, Germany
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