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Rasulova M, Vercruysse T, Paulissen J, Coun C, Suin V, Heyndrickx L, Ma J, Geerts K, Timmermans J, Mishra N, Li LH, Kum DB, Coelmont L, Van Gucht S, Karimzadeh H, Thorn-Seshold J, Rothenfußer S, Ariën KK, Neyts J, Dallmeier K, Thibaut HJ. A High-Throughput Yellow Fever Neutralization Assay. Microbiol Spectr 2022; 10:e0254821. [PMID: 35670599 PMCID: PMC9241659 DOI: 10.1128/spectrum.02548-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 05/19/2022] [Indexed: 11/20/2022] Open
Abstract
Quick and accurate detection of neutralizing antibodies (nAbs) against yellow fever is essential in serodiagnosis during outbreaks for surveillance and to evaluate vaccine efficacy in population-wide studies. All of this requires serological assays that can process a large number of samples in a highly standardized format. Albeit being laborious, time-consuming, and limited in throughput, the classical plaque reduction neutralization test (PRNT) is still considered the gold standard for the detection and quantification of nAbs due to its sensitivity and specificity. Here, we report the development of an alternative fluorescence-based serological assay (SNTFLUO) with an equally high sensitivity and specificity that is fit for high-throughput testing with the potential for automation. Finally, our novel SNTFLUO was cross-validated in several reference laboratories and against international WHO standards, showing its potential to be implemented in clinical use. SNTFLUO assays with similar performance are available for the Japanese encephalitis, Zika, and dengue viruses amenable to differential diagnostics. IMPORTANCE Fast and accurate detection of neutralizing antibodies (nAbs) against yellow fever virus (YFV) is key in yellow fever serodiagnosis, outbreak surveillance, and monitoring of vaccine efficacy. Although classical PRNT remains the gold standard for measuring YFV nAbs, this methodology suffers from inherent limitations such as low throughput and overall high labor intensity. We present a novel fluorescence-based serum neutralization test (SNTFLUO) with equally high sensitivity and specificity that is fit for processing a large number of samples in a highly standardized manner and has the potential to be implemented for clinical use. In addition, we present SNTFLUO assays with similar performance for Japanese encephalitis, Zika, and dengue viruses, opening new avenues for differential diagnostics.
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Affiliation(s)
- Madina Rasulova
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Translational Platform Virology and Chemotherapy (TPVC), Leuven, Belgium
| | - Thomas Vercruysse
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Translational Platform Virology and Chemotherapy (TPVC), Leuven, Belgium
| | - Jasmine Paulissen
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Translational Platform Virology and Chemotherapy (TPVC), Leuven, Belgium
| | - Catherina Coun
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Translational Platform Virology and Chemotherapy (TPVC), Leuven, Belgium
| | - Vanessa Suin
- Sciensano, Viral Diseases Service, Scientific Directorate of Infectious Diseases in Humans, Brussels, Belgium
| | - Leo Heyndrickx
- Virology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Ji Ma
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Katrien Geerts
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Jolien Timmermans
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Translational Platform Virology and Chemotherapy (TPVC), Leuven, Belgium
| | - Niraj Mishra
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Li-Hsin Li
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Dieudonné Buh Kum
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Lotte Coelmont
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Steven Van Gucht
- Sciensano, Viral Diseases Service, Scientific Directorate of Infectious Diseases in Humans, Brussels, Belgium
| | - Hadi Karimzadeh
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Unit Clinical Pharmacology (EKliP), Helmholtz Center for Environmental Health, Munich, Germany
| | - Julia Thorn-Seshold
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Unit Clinical Pharmacology (EKliP), Helmholtz Center for Environmental Health, Munich, Germany
| | - Simon Rothenfußer
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Unit Clinical Pharmacology (EKliP), Helmholtz Center for Environmental Health, Munich, Germany
| | - Kevin K. Ariën
- Virology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Johan Neyts
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Kai Dallmeier
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- Global Virus Network (GVN), Baltimore, Maryland, USA
| | - Hendrik Jan Thibaut
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Virology and Chemotherapy, Molecular Vaccinology & Vaccine Discovery, Leuven, Belgium
- KU Leuven Department of Microbiology, Immunology and Transplantation, Rega Institute, Translational Platform Virology and Chemotherapy (TPVC), Leuven, Belgium
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Special Issue "Endemic Arboviruses". Viruses 2022; 14:v14030645. [PMID: 35337052 PMCID: PMC8955413 DOI: 10.3390/v14030645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/10/2022] [Indexed: 12/04/2022] Open
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Nag DK, Payne AF, Dieme C, Ciota AT, Kramer LD. Zika virus infects Aedes aegypti ovaries. Virology 2021; 561:58-64. [PMID: 34147955 PMCID: PMC10117528 DOI: 10.1016/j.virol.2021.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022]
Abstract
Pathogens are transmitted from one host to another either by vertical transmission (VT) or horizontal transmission (HT). Mosquito-borne arboviruses (arthropod-borne viruses), including several clinically important viruses such as dengue, Zika, West Nile and chikungunya viruses persist in nature by both VT and HT. VT may also serve as an essential link in the transmission cycle during adverse environmental conditions. VT rates (VTRs) vary between virus families and even among viruses within the same genus. The mechanism behind these differences in VTRs among viruses is poorly understood. For efficient VT to occur, viruses must infect the mosquito germline. Here, we show that Zika virus infects mosquito ovaries and is transmitted vertically at a low rate. The infected progeny derive from mosquitoes with infected ovaries. The prevalence of ovary infection increases after a second non-infectious blood meal following an infectious blood meal.
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Affiliation(s)
- Dilip K Nag
- Arbovirus Laboratory, Wadsworth Center, New York State Department of Health, Slingerlands, NY 12159, USA.
| | - Anne F Payne
- Arbovirus Laboratory, Wadsworth Center, New York State Department of Health, Slingerlands, NY 12159, USA
| | - Constentin Dieme
- Arbovirus Laboratory, Wadsworth Center, New York State Department of Health, Slingerlands, NY 12159, USA
| | - Alexander T Ciota
- Arbovirus Laboratory, Wadsworth Center, New York State Department of Health, Slingerlands, NY 12159, USA; Department of Biomedical Sciences, School of Public Health, State University of New York, Albany, NY 12208, USA
| | - Laura D Kramer
- Arbovirus Laboratory, Wadsworth Center, New York State Department of Health, Slingerlands, NY 12159, USA; Department of Biomedical Sciences, School of Public Health, State University of New York, Albany, NY 12208, USA
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Bailey AL, Kang LI, de Assis Barros D'Elia Zanella LGF, Silveira CGT, Ho YL, Foquet L, Bial G, McCune BT, Duarte-Neto AN, Thomas A, Raué HP, Byrnes K, Kallas EG, Slifka MK, Diamond MS. Consumptive coagulopathy of severe yellow fever occurs independently of hepatocellular tropism and massive hepatic injury. Proc Natl Acad Sci U S A 2020; 117:32648-32656. [PMID: 33268494 PMCID: PMC7768776 DOI: 10.1073/pnas.2014096117] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Yellow fever (YF) is a mosquito-transmitted viral disease that causes tens of thousands of deaths each year despite the long-standing deployment of an effective vaccine. In its most severe form, YF manifests as a hemorrhagic fever that causes severe damage to visceral organs. Although coagulopathy is a defining feature of severe YF in humans, the mechanism by which it develops remains uncertain. Hepatocytes are a major target of yellow fever virus (YFV) infection, and the coagulopathy in severe YF has long been attributed to massive hepatocyte infection and destruction that results in a defect in clotting factor synthesis. However, when we analyzed blood from Brazilian patients with severe YF, we found high concentrations of plasma D-dimer, a fibrin split product, suggestive of a concurrent consumptive process. To define the relationship between coagulopathy and hepatocellular tropism, we compared infection and disease in Fah-/-, Rag2-/-, and Il2rɣ-/- mice engrafted with human hepatocytes (hFRG mice) and rhesus macaques using a highly pathogenic African YFV strain. YFV infection of macaques and hFRG mice caused substantial hepatocyte infection, liver damage, and coagulopathy as defined by virological, clinical, and pathological criteria. However, only macaques developed a consumptive coagulopathy whereas YFV-infected hFRG mice did not. Thus, infection of cell types other than hepatocytes likely contributes to the consumptive coagulopathy associated with severe YF in primates and humans. These findings expand our understanding of viral hemorrhagic disease and associated coagulopathy and suggest directions for clinical management of severe YF cases.
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Affiliation(s)
- Adam L Bailey
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110;
| | - Liang-I Kang
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110
| | | | - Cássia G T Silveira
- Division of Clinical Immunology and Allergy, School of Medicine, University of São Paulo, Sao Paulo, Brazil 01246 903
| | - Yeh-Li Ho
- Department of Infectious and Parasitic Diseases, School of Medicine, University of São Paulo, Sao Paulo, Brazil 01246 903
| | | | - Greg Bial
- Yecuris Corporation, Tualatin, OR 97062
| | - Broc T McCune
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
| | - Amaro Nunes Duarte-Neto
- Department of Pathology, Clinical Hospital, School of Medicine, University of São Paulo, Sao Paulo, Brazil 01246 903
| | - Archana Thomas
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR 97006
| | - Hans-Peter Raué
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR 97006
| | - Kathleen Byrnes
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110
| | - Esper G Kallas
- Department of Infectious and Parasitic Diseases, School of Medicine, University of São Paulo, Sao Paulo, Brazil 01246 903
| | - Mark K Slifka
- Division of Neuroscience, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR 97006
| | - Michael S Diamond
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110;
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110
- The Andrew M. and Jane M. Bursky Center for Human Immunology and Immunotherapy Programs, Washington University School of Medicine, St. Louis, MO 63110
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Parola P, Musso D. Zika, dengue, chikungunya and yellow fever infections in Europe? - Winter is over, warm days are coming - So hedge your bets. Travel Med Infect Dis 2020; 35:101614. [PMID: 32145385 DOI: 10.1016/j.tmaid.2020.101614] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 02/28/2020] [Accepted: 03/03/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Philippe Parola
- IHU-Méditerranée Infection, Marseille, France; Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France.
| | - Didier Musso
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France; Laboratoire Eurofins Labazur Guyane, French Guiana
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Le Tortorec A, Matusali G, Mahé D, Aubry F, Mazaud-Guittot S, Houzet L, Dejucq-Rainsford N. From Ancient to Emerging Infections: The Odyssey of Viruses in the Male Genital Tract. Physiol Rev 2020; 100:1349-1414. [PMID: 32031468 DOI: 10.1152/physrev.00021.2019] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The male genital tract (MGT) is the target of a number of viral infections that can have deleterious consequences at the individual, offspring, and population levels. These consequences include infertility, cancers of male organs, transmission to the embryo/fetal development abnormalities, and sexual dissemination of major viral pathogens such as human immunodeficiency virus (HIV) and hepatitis B virus. Lately, two emerging viruses, Zika and Ebola, have additionally revealed that the human MGT can constitute a reservoir for viruses cleared from peripheral circulation by the immune system, leading to their sexual transmission by cured men. This represents a concern for future epidemics and further underlines the need for a better understanding of the interplay between viruses and the MGT. We review here how viruses, from ancient viruses that integrated the germline during evolution through old viruses (e.g., papillomaviruses originating from Neanderthals) and more modern sexually transmitted infections (e.g., simian zoonotic HIV) to emerging viruses (e.g., Ebola and Zika) take advantage of genital tract colonization for horizontal dissemination, viral persistence, vertical transmission, and endogenization. The MGT immune responses to viruses and the impact of these infections are discussed. We summarize the latest data regarding the sources of viruses in semen and the complex role of this body fluid in sexual transmission. Finally, we introduce key animal findings that are relevant for our understanding of viral infection and persistence in the human MGT and suggest future research directions.
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Affiliation(s)
- Anna Le Tortorec
- University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S1085, Rennes, France
| | - Giulia Matusali
- University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S1085, Rennes, France
| | - Dominique Mahé
- University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S1085, Rennes, France
| | - Florence Aubry
- University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S1085, Rennes, France
| | - Séverine Mazaud-Guittot
- University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S1085, Rennes, France
| | - Laurent Houzet
- University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S1085, Rennes, France
| | - Nathalie Dejucq-Rainsford
- University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S1085, Rennes, France
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Girard YA, Santa Maria F, Lanteri MC. Inactivation of yellow fever virus with amotosalen and ultraviolet A light pathogen-reduction technology. Transfusion 2020; 60:622-627. [PMID: 31957887 PMCID: PMC7078960 DOI: 10.1111/trf.15673] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/14/2019] [Accepted: 10/30/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND The reemergence of yellow fever virus (YFV) in Africa and Brazil, and massive vaccine campaigns triggered to contain the outbreaks, have raised concerns over blood transfusion safety and availability with increased risk of YFV transfusion-transmitted infections (TTIs) by native and vaccine-acquired YFV. Blood donor deferral for 2 to 4 weeks following live attenuated YFV vaccination, and deferral for travel to endemic/epidemic areas, may result in blood donor loss and impact platelet component (PC) stocks. This study investigated the efficacy of INTERCEPT Blood System pathogen reduction (PR) with use of amotosalen and ultraviolet A (UVA) light to inactivate high levels of YFV in PCs. MATERIALS Four units of apheresis platelets prepared in 35% plasma/65% platelet additive solution (PC-PAS) and 4 units of PC in 100% human plasma (PC-Plasma) were spiked with high infectious titers of YFV (YFV-17D vaccine strain). YFV-17D infectious titers were measured by plaque assay and expressed as plaque-forming units (PFU) before and after amotosalen/UVA treatment to determine log reduction. RESULTS The mean YFV-17D infectious titers in PC before inactivation were 5.5 ± 0.1 log PFU/mL in PC-PAS and 5.3 ± 0.1 log PFU/mL in PC-Plasma. No infectivity was detected immediately after amotosalen/UVA treatment. CONCLUSION The amotosalen/UVA PR system inactivated high titers of infectious YFV-17D in PC. This PR technology could reduce the risk of YFV TTI and help secure PC supplies in areas experiencing YFV outbreaks where massive vaccination campaigns are required.
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Affiliation(s)
- Yvette A Girard
- Department of Microbiology, Cerus Corporation, Concord, California
| | | | - Marion C Lanteri
- Department of Scientific Affairs, Cerus Corporation, Concord, California
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Chen LH, Wilson ME. Yellow fever control: current epidemiology and vaccination strategies. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2020; 6:1. [PMID: 31938550 PMCID: PMC6954598 DOI: 10.1186/s40794-020-0101-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/05/2020] [Indexed: 12/16/2022]
Abstract
Yellow fever (YF) outbreaks continue, have expanded into new areas and threaten large populations in South America and Africa. Predicting where epidemics might occur must take into account local mosquito populations and specific YF virus strain, as well as ecoclimatic conditions, sociopolitical and demographic factors including population size, density, and mobility, and vaccine coverage. Populations of Aedes aegypti and Aedes albopictus from different regions vary in susceptibility to and capacity to transmit YF virus. YF virus cannot be eliminated today because the virus circulates in animal reservoirs, but human disease could be eliminated with wide use of the vaccine. WHO EYE (Eliminate Yellow Fever Epidemics) is a welcome plan to control YF, with strategies to be carried out from 2017 to 2026: to expand use of YF vaccine, to prevent international spread, and to contain outbreaks rapidly. YF vaccination is the mainstay in controlling YF outbreaks, but global supply is insufficient. Therefore, dose-sparing strategies have been proposed including fractional dosing and intradermal administration. Fractional dosing has been effectively used in outbreak control but currently does not satisfy International Health Regulations; special documentation is needed for international travel. Vector control is another facet in preventing YF outbreaks, and novel methods are being considered and proposed.
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Affiliation(s)
- Lin H Chen
- 1Mount Auburn Hospital, 330 Mount Auburn Street, Cambridge, MA 02138 USA.,2Harvard Medical School, Boston, MA USA
| | - Mary E Wilson
- 3Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA.,4Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, USA
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Lucey DR, Kent KR. Boosting Global Yellow Fever Vaccine Supply for Epidemic Preparedness: 3 Actions for China and the USA. Virol Sin 2019; 34:235-239. [PMID: 31127472 PMCID: PMC6599506 DOI: 10.1007/s12250-019-00129-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/21/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Daniel R Lucey
- Department of Medicine-Infectious Diseases, Georgetown University Hospital, Washington, DC, 20057, USA.
| | - Kristen R Kent
- Medical School, Georgetown University School of Medicine, Washington, DC, 20057, USA
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