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Zacharias N, Waßer F, Freier L, Spies K, Koch C, Pleischl S, Mutters NT, Kistemann T. Legionella in drinking water: the detection method matters. JOURNAL OF WATER AND HEALTH 2023; 21:884-894. [PMID: 37515560 PMCID: wh_2023_035 DOI: 10.2166/wh.2023.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Legionella concentrations in drinking water have been regulated for decades and are evaluated with regard to their concentrations in drinking water plumbing systems (DWPS). The respective action levels differ at the international level. In Germany, the Federal Environment Agency (UBA) specifies the application of ISO 11731 for the detection of legionella in drinking water and gives a binding recommendation for the methods to be used for culturing and evaluation. Effective from 01 March 2019, the UBA recommendation was revised. The utilized culture media in the culture approach were altered, consequently affecting the spectrum of legionella colonies detected in drinking water. Using data from a routine legionella monitoring of a large laboratory, over a period of 6 years and 17,270 individual drinking water samples, allowed us to assess the impact of the alteration on the assessment of DWPS. By comparing the amount of action level exceedances before and after the method change, it could be demonstrated that exceedances are reported significantly more often under the new method. Consequently, the corresponding action level for evaluation of legionella contamination and the resulting risk to human health needs to be revised to avoid the misleading impression of increased health risk.
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Affiliation(s)
- Nicole Zacharias
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany E-mail:
| | - Felix Waßer
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Lia Freier
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Kirsten Spies
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Christoph Koch
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Stefan Pleischl
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Nico T Mutters
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany
| | - Thomas Kistemann
- Institute for Hygiene and Public Health, University Hospital Bonn, Venusberg-Campus 1, Bonn 53127, Germany; Department of Geography, University of Bonn, Meckenheimer Allee 166, Bonn 53115, Germany; Centre for Development Research, University of Bonn, Genscherallee 3, Bonn 53113, Germany
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Buchholz U, Jahn HJ, Brodhun B, Lehfeld AS, Lewandowsky MM, Reber F, Adler K, Bochmann J, Förster C, Koch M, Schreiner Y, Stemmler F, Gagell C, Harbich E, Bärwolff S, Beyer A, Geuß-Fosu U, Hänel M, Larscheid P, Murajda L, Morawski K, Peters U, Pitzing R, von Welczeck A, Widders G, Wischnewski N, Abdelgawad I, Hinzmann A, Hedeler D, Schilling B, Schmidt S, Schumacher J, Zuschneid I, Atmowihardjo I, Arastéh K, Behrens S, Creutz P, Elias J, Gregor M, Kahl S, Kahnert H, Kimmel V, Lehmke J, Migaud P, Mikolajewska A, Moos V, Naumann MB, Pankow W, Scherübl H, Schmidt B, Schneider T, Stocker H, Suttorp N, Thiemig D, Gollnisch C, Mannschatz U, Haas W, Schaefer B, Lück C. Source attribution of community-acquired cases of Legionnaires' disease-results from the German LeTriWa study; Berlin, 2016-2019. PLoS One 2020; 15:e0241724. [PMID: 33237924 PMCID: PMC7688155 DOI: 10.1371/journal.pone.0241724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/20/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Sources of infection of most cases of community-acquired Legionnaires' disease (CALD) are unknown. OBJECTIVE Identification of sources of infection of CALD. SETTING Berlin; December 2016-May 2019. PARTICIPANTS Adult cases of CALD reported to district health authorities and consenting to the study; age and hospital matched controls. MAIN OUTCOME MEASURE Percentage of cases of CALD with attributed source of infection. METHODS Analysis of secondary patient samples for monoclonal antibody (MAb) type (and sequence type); questionnaire-based interviews, analysis of standard household water samples for Legionella concentration followed by MAb (and sequence) typing of Legionella pneumophila serogroup 1 (Lp1) isolates; among cases taking of additional water samples to identify the infectious source as appropriate; recruitment of control persons for comparison of exposure history and Legionella in standard household water samples. For each case an appraisal matrix was filled in to attribute any of three source types (external (non-residence) source, residential non-drinking water (RnDW) source (not directly from drinking water outlet), residential drinking water (RDW) as source) using three evidence types (microbiological results, cluster evidence, analytical-comparative evidence (using added information from controls)). RESULTS Inclusion of 111 study cases and 202 controls. Median age of cases was 67 years (range 25-93 years), 74 (67%) were male. Among 65 patients with urine typable for MAb type we found a MAb 3/1-positive strain in all of them. Compared to controls being a case was not associated with a higher Legionella concentration in standard household water samples, however, the presence of a MAb 3/1-positive strain was significantly associated (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7 to 11). Thus, a source was attributed by microbiological evidence if it contained a MAb 3/1-positive strain. A source was attributed by cluster evidence if at least two cases were exposed to the same source. Statistically significant general source types were attributed by calculating the population attributable risk (analytical-comparative evidence). We identified an external source in 16 (14%) cases, and RDW as source in 28 (25%). Wearing inadequately disinfected dentures was the only RnDW source significantly associated with cases (OR = 3.2, 95% CI 1.3 to 7.8) and led to an additional 8% of cases with source attribution, for a total of 48% of cases attributed. CONCLUSION Using the appraisal matrix we attributed almost half of all cases of CALD to an infectious source, predominantly RDW. Risk for LD seems to be conferred primarily by the type of Legionella rather than the amount. Dentures as a new infectious source needs further, in particular, integrated microbiological, molecular and epidemiological confirmation.
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Affiliation(s)
- Udo Buchholz
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Heiko Juergen Jahn
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Bonita Brodhun
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Ann-Sophie Lehfeld
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Marina M. Lewandowsky
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Franziska Reber
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Kristin Adler
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Jacqueline Bochmann
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Christina Förster
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Madlen Koch
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Yvonne Schreiner
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Fabian Stemmler
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Corinna Gagell
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Hygiene/Institute of Virology, National Consulting Laboratory for Legionella, TU Dresden, Dresden, Germany
| | - Edith Harbich
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Hygiene/Institute of Virology, National Consulting Laboratory for Legionella, TU Dresden, Dresden, Germany
| | - Sina Bärwolff
- Health Department, DHA Tempelhof-Schöneberg, Berlin, Germany
| | - Andreas Beyer
- Health Department, DHA Steglitz-Zehlendorf, Berlin, Germany
| | | | - Martina Hänel
- Health Department, DHA Marzahn-Hellersdorf, Berlin, Germany
| | | | | | | | - Uwe Peters
- Health Department, DHA Pankow, Berlin, Germany
| | - Raimund Pitzing
- Health Department, DHA Friedrichshain-Kreuzberg, Berlin, Germany
| | | | | | | | | | | | - Denis Hedeler
- Health Department, DHA Treptow-Köpenick, Berlin, Germany
| | - Birte Schilling
- Health Department, DHA Tempelhof-Schöneberg, Berlin, Germany
| | - Silvia Schmidt
- Health Department, DHA Steglitz-Zehlendorf, Berlin, Germany
| | | | - Irina Zuschneid
- Health Department, DHA Charlottenburg-Wilmersdorf, Berlin, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Uwe Mannschatz
- Hygiene Inspection for Drinking Water Systems, Berlin, Germany
| | - Walter Haas
- Department of Infectious Disease Epidemiology, Unit 36: Respiratory Infections, Robert Koch Institute, Berlin, Germany
| | - Benedikt Schaefer
- Section II 3.5 Microbiology of Drinking Water and Swimming Pool Water, German Environment Agency, Bad Elster, Germany
| | - Christian Lück
- Faculty of Medicine Carl Gustav Carus, Institute of Medical Microbiology and Hygiene/Institute of Virology, National Consulting Laboratory for Legionella, TU Dresden, Dresden, Germany
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Buchholz U, Reber F, Lehfeld AS, Brodhun B, Haas W, Schaefer B, Stemmler F, Otto C, Gagell C, Lück C, Gamradt R, Heinig M, Meisel C, Kölsch U, Eisenblätter M, Jahn HJ. Probable reinfection with Legionella pneumophila - A case report. Int J Hyg Environ Health 2018; 222:315-318. [PMID: 30501994 DOI: 10.1016/j.ijheh.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/25/2018] [Accepted: 11/07/2018] [Indexed: 11/16/2022]
Abstract
In Germany community-acquired Legionnaires' disease is usually caused by the species Legionella pneumophila. Recurrent cases of Legionnaires' disease are rarely reported and are due either to a second infection (reinfection) or a relapse of a previous case. We report a case of recurrent Legionnaires' disease in an 86-year-old female patient infected with Legionella pneumophila serogroup 1, monoclonal antibody-subtype Knoxville, sequence type unknown. Between the two disease incidents the patient had completely recovered. Legionella pneumophila was detected with the monoclonal antibody-subtype Knoxville, sequence type 182, in the drinking water of the patient's apartment. Exposure to contaminated drinking water was interrupted after the first incident exposure through the application of point-of-use water filters. The filters were later removed due to low water pressure, and the second illness occurred thereafter. It is unclear if immunological predisposition has contributed to this case of probable reinfection of Legionnaires' disease. Clinical, microbiological and epidemiological information combined suggest this is a case of reinfection of Legionnaires' disease. In cases of recurrent Legionnaires' disease complete collection of patient and water samples is necessary to differentiate relapse from reinfection cases, to implicate the source of infection and to gain more evidence for the role of immunological predisposition.
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Affiliation(s)
- Udo Buchholz
- Robert Koch Institute, Seestr. 10, Berlin, Germany.
| | | | | | | | - Walter Haas
- Robert Koch Institute, Seestr. 10, Berlin, Germany.
| | | | | | | | - Corinna Gagell
- Institute for Medical Microbiology and Hygiene, Medical Faculty "Carl Gustav Carus", Technical University Dresden, Germany.
| | - Christian Lück
- Institute for Medical Microbiology and Hygiene, Medical Faculty "Carl Gustav Carus", Technical University Dresden, Germany.
| | | | - Maxi Heinig
- Health Department of Neukölln, Berlin, Germany.
| | | | | | | | - Heiko J Jahn
- Robert Koch Institute, Seestr. 10, Berlin, Germany.
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Maisa A, Brockmann A, Renken F, Lück C, Pleischl S, Exner M, Daniels-Haardt I, Jurke A. Epidemiological investigation and case-control study: a Legionnaires' disease outbreak associated with cooling towers in Warstein, Germany, August-September 2013. ACTA ACUST UNITED AC 2016; 20:30064. [PMID: 26607018 DOI: 10.2807/1560-7917.es.2015.20.46.30064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 04/13/2015] [Indexed: 11/20/2022]
Abstract
Between 1 August and 6 September 2013, an outbreak of Legionnaires' disease (LD) with 159 suspected cases occurred in Warstein, North Rhine-Westphalia, Germany. The outbreak consisted of 78 laboratory-confirmed cases of LD, including one fatality, with a case fatality rate of 1%. Legionella pneumophila, serogroup 1, subtype Knoxville, sequence type 345, was identified as the epidemic strain. A case-control study was conducted to identify possible sources of infection. In univariable analysis, cases were almost five times more likely to smoke than controls (odds ratio (OR): 4.81; 95% confidence interval (CI): 2.33-9.93; p < 0.0001). Furthermore, cases were twice as likely to live within a 3 km distance from one identified infection source as controls (OR: 2.14; 95% CI: 1.09-4.20; p < 0.027). This is the largest outbreak of LD in Germany to date. Due to a series of uncommon events, this outbreak was most likely caused by multiple sources involving industrial cooling towers. Quick epidemiological assessment, source tracing and shutting down of potential sources as well as rapid laboratory testing and early treatment are necessary to reduce morbidity and mortality. Maintenance of cooling towers must be carried out according to specification to prevent similar LD outbreaks in the future.
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Affiliation(s)
- Anna Maisa
- Department of Infectiology and Hygiene, NRW Centre for Health, Münster, Germany
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Petzold M, Ehricht R, Slickers P, Pleischl S, Brockmann A, Exner M, Monecke S, Lück C. Rapid genotyping of Legionella pneumophila serogroup 1 strains by a novel DNA microarray-based assay during the outbreak investigation in Warstein, Germany 2013. Int J Hyg Environ Health 2016; 220:673-678. [PMID: 28501485 DOI: 10.1016/j.ijheh.2016.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/12/2016] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
Abstract
Between 1 August and 6 September 2013, an outbreak of Legionnaires' disease (LD) with 78 cases confirmed by positive urinary antigen tests occurred in Warstein, North Rhine-Westphalia, Germany. Legionella (L.) pneumophila, serogroup (Sg) 1, monoclonal antibody (mAb) subgroup Knoxville, sequence type (ST) 345, was identified as the epidemic strain. This strain was isolated from seven patients. To detect the source of the infection, epidemiological typing of clinical and environmental strains was performed in two consecutive steps. First, strains were typed by monoclonal antibodies. Indistinguishable strains were further subtyped by sequence-based typing (SBT) which is the internationally recognized standard method for epidemiological genotyping of L. pneumophila. In an early stage of the outbreak investigation, many environmental isolates were found to belong to the mAb subgroup Knoxville, but to two different STs, namely to ST 345, the epidemic strain, and to ST 600. A majority of environmental isolates belonged to ST 600 whereas the epidemic ST 345 strain was less common in environmental samples. To rapidly distinguish both Knoxville strains, we applied a novel typing method based on DNA-hybridization on glass chips. The new assay can easily and rapidly discriminate L. pneumophila Sg 1 strains. Thus, we were able to quickly identify the sources harboring the epidemic strain, i.e., two cooling towers of different companies, the waste water treatment plants (WWTP) of the city and one company as well as water samples of the river Wester and its branches.
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Affiliation(s)
- Markus Petzold
- Institute of Medical Microbiology and Hygiene, German Reference Laboratory for Legionella, Dresden University of Technology, Fetscherstraße 74, 01307 Dresden, Germany.
| | - Ralf Ehricht
- Alere Technologies GmbH, Löbstedter Straße 103-105, 07749 Jena, Germany.
| | - Peter Slickers
- Alere Technologies GmbH, Löbstedter Straße 103-105, 07749 Jena, Germany.
| | - Stefan Pleischl
- Institute for Hygiene and Public Health, University of Bonn, Sigmund-Freud-Straße 25, 53105 Bonn, Germany.
| | - Ansgar Brockmann
- Regional Public Health Department Soest, Mastholter Straße 230, 59558 Lippstadt, Germany.
| | - Martin Exner
- Institute for Hygiene and Public Health, University of Bonn, Sigmund-Freud-Straße 25, 53105 Bonn, Germany.
| | - Stefan Monecke
- Institute of Medical Microbiology and Hygiene, German Reference Laboratory for Legionella, Dresden University of Technology, Fetscherstraße 74, 01307 Dresden, Germany; Alere Technologies GmbH, Löbstedter Straße 103-105, 07749 Jena, Germany.
| | - Christian Lück
- Institute of Medical Microbiology and Hygiene, German Reference Laboratory for Legionella, Dresden University of Technology, Fetscherstraße 74, 01307 Dresden, Germany.
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Zacharias N, Kistemann T, Schreiber C. Application of flow cytometry and PMA-qPCR to distinguish between membrane intact and membrane compromised bacteria cells in an aquatic milieu. Int J Hyg Environ Health 2015; 218:714-22. [DOI: 10.1016/j.ijheh.2015.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 03/30/2015] [Accepted: 04/01/2015] [Indexed: 11/17/2022]
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Cassier P, Campese C, Le Strat Y, Che D, Ginevra C, Etienne J, Jarraud S. Epidemiologic characteristics associated with ST23 clones compared to ST1 and ST47 clones of Legionnaires disease cases in France. New Microbes New Infect 2014; 3:29-33. [PMID: 25755889 PMCID: PMC4337934 DOI: 10.1016/j.nmni.2014.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/30/2014] [Indexed: 11/19/2022] Open
Abstract
In France, approximately 1200 cases of Legionnaires disease (LD) are reported annually, and isolates are available for approximately 20% of cases identified since 2000. All Legionella pneumophila serogroup 1 (sg1) isolates are characterized by sequence-based typing at the National Reference Centre. LD cases caused by L. pneumophila sg1 reported from 2008 through 2012 were considered for the study. Our study objective was to describe cases according to their sequence type (ST). We also constructed multivariable modified Poisson regression models to estimate the incidence rate ratio (IRR) and to identify characteristics potentially associated with ST23 clones compared to ST1 and ST47 clones. We studied 1192 patients infected by ST1 (n = 109), ST23 (n = 236), ST47 (n = 123) or other STs (n = 724). The geographic distribution of the ST23 cases across the country was significantly different compared to other ST groups. This genotype was significantly associated with the absence of corticosteroid therapy compared to ST1 (IRR = 0.56; p 0.016). Concerning exposure, the ST23 genotype was significantly less associated with hospital-acquired infections compared to ST1 (IRR = 0.32; p 0.001), but it was more associated with infections acquired in hospitals and elderly settings compared with ST47. Finally, the ST23 genotype was less frequently associated with travel than other STs. Despite the large number of cases of ST23 infection, we did not identify any characteristics specific to this ST. However, we identified independent associations between ST1 and nosocomial transmission and steroid therapy. These findings should encourage further exploration, especially in terms of environmental diffusion, strain virulence and host factors.
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Affiliation(s)
- P. Cassier
- Hospices Civils de Lyon, National Reference Centre of Legionella, Centre de Biologie Est, France
- CIRI, International Center for Infectiology Research, Legionella Pathogenosis Team, Université de Lyon, France
- Inserm, U1111, France
- Ecole Normale Supérieure de Lyon, France
- Université Lyon 1, Centre International de Recherche en Infectiologie, France
- CNRS, UMR5308, Lyon, France
- Corresponding author: P. Cassier, Hospices Civils de Lyon, National Reference Centre of Legionella, Centre de Biologie Est, 59 Bd Pinel 69500 Bron, France.
| | - C. Campese
- French Institute for Public Health Surveillance, Saint Maurice, France
| | - Y. Le Strat
- French Institute for Public Health Surveillance, Saint Maurice, France
| | - D. Che
- French Institute for Public Health Surveillance, Saint Maurice, France
| | - C. Ginevra
- Hospices Civils de Lyon, National Reference Centre of Legionella, Centre de Biologie Est, France
- CIRI, International Center for Infectiology Research, Legionella Pathogenosis Team, Université de Lyon, France
- Inserm, U1111, France
- Ecole Normale Supérieure de Lyon, France
- Université Lyon 1, Centre International de Recherche en Infectiologie, France
- CNRS, UMR5308, Lyon, France
| | - J. Etienne
- Hospices Civils de Lyon, National Reference Centre of Legionella, Centre de Biologie Est, France
| | - S. Jarraud
- Hospices Civils de Lyon, National Reference Centre of Legionella, Centre de Biologie Est, France
- CIRI, International Center for Infectiology Research, Legionella Pathogenosis Team, Université de Lyon, France
- Inserm, U1111, France
- Ecole Normale Supérieure de Lyon, France
- Université Lyon 1, Centre International de Recherche en Infectiologie, France
- CNRS, UMR5308, Lyon, France
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