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Kawasuji H, Morinaga Y, Tani H, Yamada H, Yoshida Y, Ezaki M, Koshiyama Y, Takegoshi Y, Kaneda M, Murai Y, Kimoto K, Nagaoka K, Niimi H, Yamamoto Y. Low pre-infection levels of neutralizing antibody in breakthrough infections after bivalent BA.4-5 vaccine and practical application of dried blood spots. Vaccine 2024; 42:126029. [PMID: 38839519 DOI: 10.1016/j.vaccine.2024.05.077] [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: 02/16/2024] [Revised: 05/07/2024] [Accepted: 05/31/2024] [Indexed: 06/07/2024]
Abstract
The level of neutralizing antibodies required to confer protection against COVID-19 breakthrough infections (BIs) is unclear, and the ability to know the immune status of individuals against the rapidly changing endemic variants is limited. We assessed longitudinal serum anti-RBD antibody levels and neutralizing activities (NTs) against Omicron BA.5 and XBB.1.5 in healthcare workers following the fourth monovalent and fifth bivalent BA.4-5 vaccines. The occurrence of BIs was also followed, and pre-infection antibody levels were compared between patients who developed BI and those who did not. In addition, we collected whole blood samples on the same day as the sera and stored them on filter papers (nos. 545, 590, and 424) for up to two months, then measured their NTs using dried blood spots (DBS) eluates, and compared them with the NTs in paired sera. Pre-infection levels of NTs were lower in patients who developed BI than those who did not, but the anti-RBD antibody levels were not different between them. The NTs below 50 % using 200-fold diluted sera might be one of the indicators of high risk for COVID-19 BI. However, the NTs against XBB.1.5 at 6 months after the fifth dose of bivalent BA.4-5 vaccine were lower than this threshold in almost half of infection-naïve participants. NTs measured using DBS eluates were strongly correlated with those measured using paired sera, but the time and temperature stability varied with the type of filter paper; no. 545 filter paper was found to most suitable for NT evaluation.
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Affiliation(s)
- Hitoshi Kawasuji
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.
| | - Hideki Tani
- Department of Virology, Toyama Institute of Health, Toyama, Japan
| | - Hiroshi Yamada
- Department of Microbiology, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Yoshihiro Yoshida
- Department of Microbiology, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Masayoshi Ezaki
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Yuki Koshiyama
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Yusuke Takegoshi
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Makito Kaneda
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Yushi Murai
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Kou Kimoto
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Kentaro Nagaoka
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Hideki Niimi
- Department of Clinical Laboratory and Molecular Pathology, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
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2
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Gutiérrez-Bautista JF, Díaz-Alberola I, Tarriño M, Aguilera M, Cobo F, Reguera JA, Rodríguez-Granger J, Mendoza J, López-Nevot MÁ, Sampedro A. Follow-up of immune response in patients with common variable immunodeficiency following SARS-CoV-2 vaccination. Clin Exp Immunol 2024; 217:253-262. [PMID: 38693777 PMCID: PMC11310691 DOI: 10.1093/cei/uxae039] [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: 02/05/2024] [Revised: 03/13/2024] [Accepted: 05/01/2024] [Indexed: 05/03/2024] Open
Abstract
The COVID-19 pandemic highlighted the importance of effective vaccination strategies in controlling the spread of infectious diseases. SARS-CoV-2 vaccine has demonstrated high efficacy in preventing COVID-19 infection in the general population. However, the efficacy of this vaccine in patients with predominantly antibody deficiencies, such as common variable immunodeficiency (CVID) and X-linked agammaglobulinemia (XLA), should be closely monitored. CVID and XLA are rare genetic disorders that impair the immune system's ability to produce antibodies, which are crucial for fighting infections. Patients with these disorders have a higher risk of severe disease and mortality from COVID-19 due to their compromised immune systems. In this study, we evaluated the humoral and cellular immune responses after four doses of mRNA-1273 and one BNT162b2 bivalent vaccine in a cohort of patients with CVID and XLA. The response in this population was lower than in the control group. However, the administration of the third dose improved the number of patients with seroconversion and the intensity of the humoral response, as well as the number of patients with a positive cellular response. Finally, the administration of the fourth and fifth doses improves the antibody titer and neutralization against wild type variant, but not against the prevalent XBB1.5 variant.
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Affiliation(s)
- Juan Francisco Gutiérrez-Bautista
- Departamento de Bioquímica, Biología Molecular e Inmunología III, University of Granada, Granada, Spain
- Servicio de Análisis Clínicos e Inmunología, University Hospital Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
| | - Irene Díaz-Alberola
- Servicio de Análisis Clínicos e Inmunología, University Hospital Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
| | - María Tarriño
- Servicio de Microbiología, University Hospital Virgen de las Nieves, Granada, Spain
| | - María Aguilera
- Servicio de Microbiología, University Hospital Virgen de las Nieves, Granada, Spain
| | - Fernando Cobo
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
- Servicio de Microbiología, University Hospital Virgen de las Nieves, Granada, Spain
| | - Juan Antonio Reguera
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
- Servicio de Microbiología, University Hospital Virgen de las Nieves, Granada, Spain
| | - Javier Rodríguez-Granger
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
- Servicio de Microbiología, University Hospital Virgen de las Nieves, Granada, Spain
| | | | - Miguel Ángel López-Nevot
- Departamento de Bioquímica, Biología Molecular e Inmunología III, University of Granada, Granada, Spain
- Servicio de Análisis Clínicos e Inmunología, University Hospital Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
| | - Antonio Sampedro
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), Granada, Spain
- Servicio de Microbiología, University Hospital Virgen de las Nieves, Granada, Spain
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3
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Amano M, Ichikawa Y, Matsumoto S, Higashi-Kuwata N, Takamatsu Y, Matsushita S, Shimada S, Mitsuya H. Neutralization activity of HCWs' sera after Omicron XBB.1.5-adapted monovalent COVID-19 mRNA vaccination. J Infect 2024; 89:106179. [PMID: 38740288 DOI: 10.1016/j.jinf.2024.106179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Masayuki Amano
- Department of Clinical Retrovirology, Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto, Japan.
| | - Yasuko Ichikawa
- Kumamoto General Hospital, Japan Community Healthcare Organization, Kumamoto, Japan
| | - Shota Matsumoto
- Kumamoto General Hospital, Japan Community Healthcare Organization, Kumamoto, Japan
| | - Nobuyo Higashi-Kuwata
- Department of Refractory Viral Infections, National Center for Global Health and Medicine Research Institute, Tokyo, Japan
| | - Yuki Takamatsu
- Department of Refractory Viral Infections, National Center for Global Health and Medicine Research Institute, Tokyo, Japan
| | - Shuzo Matsushita
- Department of Clinical Retrovirology, Joint Research Center for Human Retrovirus Infection, Kumamoto University, Kumamoto, Japan
| | - Shinya Shimada
- Kumamoto General Hospital, Japan Community Healthcare Organization, Kumamoto, Japan
| | - Hiroaki Mitsuya
- Department of Refractory Viral Infections, National Center for Global Health and Medicine Research Institute, Tokyo, Japan
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Ameratunga R, Jordan A, Lehnert K, Leung E, Mears ER, Snell R, Steele R, Woon ST. SARS-CoV-2 evolution has increased resistance to monoclonal antibodies and first-generation COVID-19 vaccines: Is there a future therapeutic role for soluble ACE2 receptors for COVID-19? Antiviral Res 2024; 227:105894. [PMID: 38677595 DOI: 10.1016/j.antiviral.2024.105894] [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: 01/24/2024] [Revised: 04/17/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024]
Abstract
COVID-19 has caused calamitous health, economic and societal consequences. Although several COVID-19 vaccines have received full authorization for use, global deployment has faced political, financial and logistical challenges. The efficacy of first-generation COVID-19 vaccines is waning and breakthrough infections are allowing ongoing transmission and evolution of SARS-CoV-2. Furthermore, COVID-19 vaccine efficacy relies on a functional immune system. Despite receiving three primary doses and three or more heterologous boosters, some immunocompromised patients may not be adequately protected by COVID-19 vaccines and remain vulnerable to severe disease. The evolution of new SARS-CoV-2 variants has also resulted in the rapid obsolescence of monoclonal antibodies. Convalescent plasma from COVID-19 survivors has produced inconsistent results. New drugs such as Paxlovid (nirmatrelvir/ritonavir) are beyond the reach of low- and middle-income countries. With widespread use of Paxlovid, it is likely nirmatrelvir-resistant clades of SARS-CoV-2 will emerge in the future. There is thus an urgent need for new effective anti-SARS-CoV-2 treatments. The in vitro efficacy of soluble ACE2 against multiple SARS-CoV-2 variants including omicron (B.1.1.529), was recently described using a competitive ELISA assay as a surrogate marker for virus neutralization. This indicates soluble wild-type ACE2 receptors are likely to be resistant to viral evolution. Nasal and inhaled treatment with soluble ACE2 receptors has abrogated severe disease in animal models of COVID-19. There is an urgent need for clinical trials of this new class of antiviral therapeutics, which could complement vaccines and Paxlovid.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton, 1010, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton, 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Anthony Jordan
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton, 1010, Auckland, New Zealand
| | - Klaus Lehnert
- Applied Translational Genetics Group, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Euphemia Leung
- Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Emily R Mears
- Applied Translational Genetics Group, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Russell Snell
- Applied Translational Genetics Group, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton, 1010, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton, 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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5
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Matusali G, Vergori A, Cimini E, Mariotti D, Mazzotta V, Lepri AC, Colavita F, Gagliardini R, Notari S, Meschi S, Fusto M, Tartaglia E, Girardi E, Maggi F, Antinori A. Poor durability of the neutralizing response against XBB sublineages after a bivalent mRNA COVID-19 booster dose in persons with HIV. J Med Virol 2024; 96:e29598. [PMID: 38624044 DOI: 10.1002/jmv.29598] [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: 01/04/2024] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
We estimated the dynamics of the neutralizing response against XBB sublineages and T cell response in persons with HIV (PWH) with previous AIDS and/or CD4 < 200/mm3 receiving the bivalent original strain/BA.4-5 booster dose in fall 2022. Samples were collected before the shot (Day 0), 15 days, 3, and 6 months after. PWH were stratified by immunization status: hybrid immunity (HI; vaccination plus COVID-19) versus nonhybrid immunity (nHI; vaccination only). Fifteen days after the booster, 16% and 30% of PWH were nonresponders in terms of anti-XBB.1.16 or anti-EG.5.1 nAbs, respectively. Three months after, a significant waning of anti-XBB.1.16, EG.5.1 and -XBB.1 nAbs was observed both in HI and nHI but nAbs in HI were higher than in nHI. Six months after both HI and nHI individuals displayed low mean levels of anti-XBB.1.16 and EG.5.1 nAbs. Regarding T cell response, IFN-γ values were stable over time and similar in HI and nHI. Our data showed that in PWH, during the prevalent circulation of the XBB.1.16, EG.5.1, and other XBB sublineages, a mRNA bivalent vaccine might not confer broad protection against them. With a view to the 2023/2024 vaccination campaign, the use of the monovalent XBB.1.5 mRNA vaccine should be urgently warranted in PWH to provide adequate protection.
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Affiliation(s)
- Giulia Matusali
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Alessandra Vergori
- Viral Immunodeficiency Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Eleonora Cimini
- Immunology Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Davide Mariotti
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Valentina Mazzotta
- Viral Immunodeficiency Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Alessandro Cozzi Lepri
- Institute for Global Health, University College of London, Centre for Clinical Research, Epidemiology, Modeling and Evaluation (CREME), London, UK
| | - Francesca Colavita
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Roberta Gagliardini
- Viral Immunodeficiency Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Stefania Notari
- Immunology Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Silvia Meschi
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Marisa Fusto
- Viral Immunodeficiency Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Eleonora Tartaglia
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Enrico Girardi
- Scientific Direction, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Fabrizio Maggi
- Laboratory of Virology, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
| | - Andrea Antinori
- Viral Immunodeficiency Unit, National Institute for Infectious Diseases Lazzaro Spallanzani, IRCCS, Rome, Italy
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6
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Nantel S, Sheikh-Mohamed S, Chao GYC, Kurtesi A, Hu Q, Wood H, Colwill K, Li Z, Liu Y, Seifried L, Bourdin B, McGeer A, Hardy WR, Rojas OL, Al-Aubodah TA, Liu Z, Ostrowski MA, Brockman MA, Piccirillo CA, Quach C, Rini JM, Gingras AC, Decaluwe H, Gommerman JL. Comparison of Omicron breakthrough infection versus monovalent SARS-CoV-2 intramuscular booster reveals differences in mucosal and systemic humoral immunity. Mucosal Immunol 2024; 17:201-210. [PMID: 38278415 DOI: 10.1016/j.mucimm.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/17/2024] [Accepted: 01/20/2024] [Indexed: 01/28/2024]
Abstract
Our understanding of the quality of cellular and humoral immunity conferred by COVID-19 vaccination alone versus vaccination plus SARS-CoV-2 breakthrough (BT) infection remains incomplete. While the current (2023) SARS-CoV-2 immune landscape of Canadians is complex, in late 2021 most Canadians had either just received a third dose of COVID-19 vaccine, or had received their two-dose primary series and then experienced an Omicron BT. Herein we took advantage of this coincident timing to contrast cellular and humoral immunity conferred by three doses of vaccine versus two doses plus BT. Our results show thatBT infection induces cell-mediated immune responses to variants comparable to an intramuscular vaccine booster dose. In contrast, BT subjects had higher salivary immunoglobulin (Ig)G and IgA levels against the Omicron spike and enhanced reactivity to the ancestral spike for the IgA isotype, which also reacted with SARS-CoV-1. Serumneutralizing antibody levels against the ancestral strain and the variants were also higher after BT infection. Our results support the need for the development of intranasal vaccines that could emulate the enhanced mucosal and humoral immunity induced by Omicron BT without exposing individuals to the risks associated with SARS-CoV-2 infection.
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Affiliation(s)
- Sabryna Nantel
- Sainte-Justine University Hospital and Research Center, Montréal, Québec, Canada; Microbiology, Infectiology and Immunology Department, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
| | | | - Gary Y C Chao
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Kurtesi
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - Queenie Hu
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - Heidi Wood
- One Health Division, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Karen Colwill
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - Zhijie Li
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Ying Liu
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Laurie Seifried
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - Benoîte Bourdin
- Sainte-Justine University Hospital and Research Center, Montréal, Québec, Canada
| | - Allison McGeer
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - William R Hardy
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - Olga L Rojas
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada; Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Tho-Alfakar Al-Aubodah
- Department of Microbiology and Immunology, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada; Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Zhiyang Liu
- Department of Microbiology and Immunology, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada; Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Mario A Ostrowski
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Mark A Brockman
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Ciriaco A Piccirillo
- Department of Microbiology and Immunology, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada; Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Caroline Quach
- Sainte-Justine University Hospital and Research Center, Montréal, Québec, Canada; Microbiology, Infectiology and Immunology Department, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
| | - James M Rini
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada; Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada
| | - Anne-Claude Gingras
- Lunenfeld-Tanenbaum Research Institute at Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada; Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Hélène Decaluwe
- Sainte-Justine University Hospital and Research Center, Montréal, Québec, Canada; Microbiology, Infectiology and Immunology Department, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada; Pediatric Immunology and Rheumatology Division, Department of Pediatrics, University of Montréal, Montréal, Québec, Canada.
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