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Dauby N, Gagneux-Brunon A, Martin C, Mussi-Pinhata MM, Goetghebuer T. Maternal immunization in women living with HIV. AIDS 2024; 38:137-144. [PMID: 38116721 DOI: 10.1097/qad.0000000000003758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Thanks to widespread use of antiretroviral therapy worldwide, women living with HIV (WLWH) are becoming pregnant and giving birth to HIV-exposed but uninfected (HEU) newborns. Both pregnancy and HIV infection-related factors such as low CD4+ T-cell count or uncontrolled viral load increase the risk of severe infections such as influenza, COVID-19, and others, making maternal immunization a valuable tool to decrease maternal morbidity among WLWH. Vaccines administered during pregnancy may also benefit the health of HEU infants. Indeed, HEU infants suffer from higher risk of morbidity of infectious origin, including respiratory syncytial virus (RSV), group B streptococcus (GBS), pneumococcus and pertussis infections. Maternal pertussis immunization is recommended in various high-income countries but not in many low-middle income countries where HIV prevalence is higher. GBS and RSV vaccines to be administered during pregnancy are currently in late-phase clinical trials in HIV-uninfected women and could represent a valuable tool to decrease morbidity during infancy. Decreased transfer of vaccine-specific IgG, accelerated waning of vaccine-induced antibody responses, linked to persistent maternal immune activation, and blunting of infant immune response to vaccines could hamper vaccine effectiveness among WLWH and HEU infants. Vaccine hesitancy could limit benefits of maternal immunization and strategies to tackle vaccine hesitancy should be part of HIV routine care. The aim of this review is to summarize the current knowledge regarding the immunogenicity and efficacy of available and upcoming vaccines recommended during pregnancy of WLWH.
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Affiliation(s)
- Nicolas Dauby
- Department of Infectious Diseases, CHU Saint-Pierre
- School of Public Health
- U-CRI, Université libre de Bruxelles (ULB), Brussels, Belgium
| | | | | | | | - Tessa Goetghebuer
- Department of Paediatrics, CHU Saint-Pierre, Université libre de Bruxelles (ULB), Brussels, Belgium
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2
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van Halsema CL, Eades CP, Johnston VJ, Miller RF. British HIV Association guidelines on the management of opportunistic infection in people living with HIV: The clinical investigation and management of pyrexia of unknown origin 2023. HIV Med 2023; 24 Suppl 4:3-18. [PMID: 37956976 DOI: 10.1111/hiv.13558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 11/21/2023]
Affiliation(s)
- C L van Halsema
- Regional infectious diseases unit, Manchester University NHS Foundation Trust
| | - C P Eades
- Regional infectious diseases unit, Manchester University NHS Foundation Trust
- University of Manchester
| | - V J Johnston
- London School of Hygiene & Tropical Medicine
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust
| | - R F Miller
- London School of Hygiene & Tropical Medicine
- Institute for Global Health, University College London
- Central & North West London NHS Foundation Trust
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3
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Phuong LK, Cheung A, Agrawal R, Butters C, Buttery J, Clark J, Connell T, Curtis N, Daley AJ, Dobinson HC, Frith C, Hameed NS, Hernstadt H, Krieser DM, Loke P, Ojaimi S, McMullan B, Pinzon-Charry A, Sharp EG, Sinnappurajar P, Templeton T, Wen S, Cole T, Gwee A. Inborn Errors of Immunity in Children With Invasive Pneumococcal Disease: A Multicenter Prospective Study. Pediatr Infect Dis J 2023; 42:908-913. [PMID: 37463351 DOI: 10.1097/inf.0000000000004004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND In settings with universal conjugate pneumococcal vaccination, invasive pneumococcal disease (IPD) can be a marker of an underlying inborn error of immunity. The aim of this study was to determine the prevalence and characterize the types of immunodeficiencies in children presenting with IPD. METHODS Multicenter prospective audit following the introduction of routinely recommended immunological screening in children presenting with IPD. The minimum immunological evaluation comprised a full blood examination and film, serum immunoglobulins (IgG, IgA and IgM), complement levels and function. Included participants were children in whom Streptococcus pneumoniae was isolated from a normally sterile site (cerebrospinal fluid, pleura, peritoneum and synovium). If isolated from blood, features of sepsis needed to be present. Children with predisposing factors for IPD (nephrotic syndrome, anatomical defect or malignancy) were excluded. RESULTS Overall, there were 379 episodes of IPD of which 313 (83%) were eligible for inclusion and 143/313 (46%) had an immunologic evaluation. Of these, 17/143 (12%) were diagnosed with a clinically significant abnormality: hypogammaglobulinemia (n = 4), IgA deficiency (n = 3), common variable immunodeficiency (n = 2), asplenia (n = 2), specific antibody deficiency (n = 2), incontinentia pigmenti with immunologic dysfunction (n = 1), alternative complement deficiency (n = 1), complement factor H deficiency (n = 1) and congenital disorder of glycosylation (n = 1). The number needed to investigate to identify 1 child presenting with IPD with an immunologic abnormality was 7 for children under 2 years and 9 for those 2 years old and over. CONCLUSIONS This study supports the routine immune evaluation of children presenting with IPD of any age, with consideration of referral to a pediatric immunologist.
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Affiliation(s)
- Linny Kimly Phuong
- From the Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Microbiology, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Abigail Cheung
- Department of Allergy and Clinical Immunology, Women's and Children's Hospital, South Australia
- General Paediatric and Adolescent Medicine, John Hunter Children's Hospital, New Lambton, Australia
| | - Rishi Agrawal
- Department of General Medicine, Women's and Children's Hospital, South Australia
| | - Coen Butters
- Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- General Paediatric and Adolescent Medicine, John Hunter Children's Hospital, New Lambton, Australia
| | - Jim Buttery
- From the Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Julia Clark
- Infection Management Prevention Service, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Tom Connell
- From the Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Nigel Curtis
- From the Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew J Daley
- Department of Microbiology, Royal Children's Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Hazel C Dobinson
- Department of Paediatrics and Child Health, Te Whatu Ora Capital, Coast and Hutt Valley, Wellington, New Zealand
| | - Catherine Frith
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick
| | | | - Hayley Hernstadt
- Department of Paediatrics, Monash Children's Hospital, Monash Health, Clayton, Victoria, Australia
| | - David M Krieser
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Paediatric Emergency Medicine, Sunshine Hospital, St Albans, Victoria, Australia
| | - Paxton Loke
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Allergy & Immunology, Murdoch Children's Research Institute, Melbourne, Australia
- Monash Pathology, Monash Health; Clayton, Victoria, Australia
| | - Samar Ojaimi
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Allergy & Immunology, Murdoch Children's Research Institute, Melbourne, Australia
- Monash Pathology, Monash Health; Clayton, Victoria, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick
| | - Alberto Pinzon-Charry
- Infection Management Prevention Service, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Queensland, Australia
- Queensland Paediatric Immunology & Allergy Service, Queensland Children's Hospital, Queensland, Australia
- Griffith University, Brisbane, Queensland, Australia
| | - Ella Grace Sharp
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick
| | | | - Tiarni Templeton
- Infection Management Prevention Service, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Sophie Wen
- Infection Management Prevention Service, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Theresa Cole
- Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Amanda Gwee
- From the Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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Mamani RF, López TDA, Jalo WM, Alves MR, Nunes EP, Pereira MS, Silva EADSRD, Lourenço MCDS, Veloso VG, Grinsztejn BJ, Cardoso SW, Lamas CDC. Invasive Pneumococcal Disease in People Living with HIV: A Retrospective Case-Control Study in Brazil. Trop Med Infect Dis 2023; 8:328. [PMID: 37368746 DOI: 10.3390/tropicalmed8060328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
HIV-infected patients are at particular risk for invasive pneumococcal disease (IPD). We describe cases of IPD in people living with HIV/AIDS (PLWHA) and find associated risk factors for infection and death. METHODS A retrospective case-control study, nested in a cohort, including PLWHA with and without IPD, conducted in Brazil, 2005-2020. Controls were of the same gender/age and seen at the same time/place as cases. RESULTS We identified 55 episodes of IPD (cases) in 45 patients and 108 controls. The incidence of IPD was 964/100,000 person-years. A total of 42 of 55 (76.4%) IPD episodes presented with pneumonia and 11 (20%) with bacteremia without a focus and 38/45 (84.4%) were hospitalized. Blood cultures were positive in 54/55 (98.2%). Liver cirrhosis and COPD were the only factors associated with IPD in PLWHA in univariate analysis, although no associated factors were found in multivariate analysis. Penicillin resistance was found in 4/45 (8.9%). Regarding antiretroviral therapy (ART), 40/45 (88.9%) cases vs. 80/102 controls (74.1%) were in use (p = 0.07). Patients with HIV and IPD had a higher CD4 count of 267 cells/mm3 compared with the control group, in which it was 140 cells/mm3 (p = 0.027). Pneumococcal vaccination was documented in 19%. Alcoholism (p = 0.018), hepatic cirrhosis (p = 0.003), and lower nadir CD4 count (p = 0.033) were associated with the risk of death in patients with IPD. In-hospital mortality among PLWHA and IPD was 21.1%, and it was associated with thrombocytopenia and hypoalbuminemia, elevated band forms, creatinine, and aspartate aminotransferase (AST). CONCLUSIONS The incidence of IPD in PLWHA remained high despite ART. The vaccination rate was low. Liver cirrhosis was associated with IPD and death.
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Affiliation(s)
- Roxana Flores Mamani
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Tiago de Assunção López
- Barra da Tijuca Campus, Department of Medicine, Universidade do Grande Rio/Afya, Avenida Ayrton Senna, 2.200, Barra da Tijuca 22775-003, RJ, Brazil
| | - Waldir Madany Jalo
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Marcelo Ribeiro Alves
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Estevão Portela Nunes
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Mario Sérgio Pereira
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | | | - Maria Cristina da Silva Lourenço
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Valdiléa Gonçalves Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Beatriz Jegerhorn Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Sandra Wagner Cardoso
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Cristiane da Cruz Lamas
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
- Instituto Nacional de Cardiologia, Rua das Laranjeiras, 374-Laranjeiras, Rio de Janeiro 22240-006, RJ, Brazil
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Campling J, Vyse A, Liu HH, Wright H, Slack M, Reinert RR, Drayson M, Richter A, Singh D, Barlow G, Kassianos G, Ellsbury G. A review of evidence for pneumococcal vaccination in adults at increased risk of pneumococcal disease: risk group definitions and optimization of vaccination coverage in the United Kingdom. Expert Rev Vaccines 2023; 22:785-800. [PMID: 37694398 DOI: 10.1080/14760584.2023.2256394] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Pneumococcal disease (PD) significantly contributes to morbidity and mortality, carrying substantial economic and public health burden. This article is a targeted review of evidence for pneumococcal vaccination in the UK, the definitions of groups at particular risk of PD and vaccine effectiveness. AREAS COVERED Relevant evidence focusing on UK data from surveillance systems, randomized controlled trials, observational studies and publicly available government documents is collated and reviewed. Selected global data are included where appropriate. EXPERT OPINION National vaccination programs have reduced the incidence of vaccine-type PD, despite the rising prominence of non-vaccine serotypes in the UK. The introduction of higher-valency conjugate vaccines provides an opportunity to improve protection against PD for adults in risk groups. Several incentives are in place to encourage general practitioners to vaccinate risk groups, but uptake is low-suboptimal particularly among at-risk individuals. Wider awareness and understanding among the public and healthcare professionals may increase vaccination uptake and coverage. National strategies targeting organizational factors are urgently needed to achieve optimal access to vaccines. Finally, identifying new risk factors and approaches to risk assessment for PD are crucial to ensure those at risk of PD can benefit from pneumococcal vaccination.
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Affiliation(s)
| | - Andrew Vyse
- Medical Affairs, Pfizer Ltd, Walton Oaks, UK
| | | | | | - Mary Slack
- School of Medicine & Dentistry, Griffith University, Southport, Queensland, Australia
| | | | - Mark Drayson
- Institute of Immunology and Immunotherapy, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Alex Richter
- Institute of Immunology and Immunotherapy, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Dave Singh
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Gavin Barlow
- Hull York Medical School, University of York, York, UK
| | - George Kassianos
- Royal College of General Practitioners, London, UK
- British Global & Travel Health Association, Bath, UK
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Duarte G, Muresan P, Ward S, Laimon L, Pelton SI, Canniff J, Golner A, Bone F, Newton L, Fenton T, Coutinho CM, João EC, Santos BR, Pilotto JH, Oliveira RH, Pinto JA, Machado ES, Kreitchman R, Chakhtoura N, Mussi-Pinhata MM, Weinberg A. Immunogenicity of conjugated and polysaccharide pneumococcal vaccines administered during pregnancy or postpartum to women with HIV. J Infect Dis 2021; 225:1021-1031. [PMID: 34791324 DOI: 10.1093/infdis/jiab567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pneumococcal vaccination is recommended in people with HIV prioritizing PCV. We compared the immunogenicity of PCV-10 and PPV-23 administered antepartum or postpartum. METHODS This double-blind study randomized 346 pregnant women with HIV on antiretrovirals to PCV-10, PPV-23, or placebo at 14-34 weeks gestational age. Women who received placebo antepartum were randomized at 24 weeks postpartum to PCV-10 or PPV-23. Antibodies against seven serotypes common to both vaccines and one serotype only in PPV-23 were measured by ELISA/chemiluminescence; B- and T-cell responses to serotype-1 by FLUOROSPOT; and plasma cytokines/chemokines by chemiluminescence. RESULTS Antibody responses were higher after postpartum versus antepartum vaccination. PCV-10 generated lower antibody levels than PPV-23 against four and higher against one of seven common serotypes. Additional factors associated with high post-vaccination antibody concentrations were high pre-vaccination antibody concentrations and CD4+ cells; low CD8+ cells and plasma HIV RNA; and several plasma cytokines/chemokines. Serotype-1 B- and T-cell memory did not increase after vaccination. CONCLUSIONS Antepartum immunization generated suboptimal antibody responses, suggesting that postpartum booster doses may be beneficial and warrant further studies. Considering that PCV-10 and PPV-23 had similar immunogenicity, but PPV-23 covered more serotypes, the use of PPV-23 may be prioritized in women with HIV on ART.
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Affiliation(s)
- Geraldo Duarte
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | | | - Shawn Ward
- Frontier Science Foundation, Brookline, MA, USA
| | | | | | - Jennifer Canniff
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | | | - Conrado M Coutinho
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Esau C João
- Hospital dos Servidores Estaduais, Rio de Janeiro, RJ, Brazil
| | - Breno R Santos
- Hospital Nossa Senhora da Conceicao, Porto Alegre, RGS, Brazil
| | - Jose H Pilotto
- Hospital Geral de Nova Iguaçu & Laboratório de AIDS e Imunologia Molecular - Fiocruz, Rio de Janeiro, Brazil
| | - Ricardo H Oliveira
- Instituto de Puericultura e Pediatra Matagão Gesteira, Rio de Janeiro, RJ, Brazil
| | - Jorge A Pinto
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Elizabeth S Machado
- Instituto de Puericultura e Pediatra Matagão Gesteira, Rio de Janeiro, RJ, Brazil
| | | | - Nahida Chakhtoura
- Eunice Kennedy Shriver National Institute of Child Health & Human Development, Bethesda, MD, USA
| | - Marisa M Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Adriana Weinberg
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Tinggaard M, Slotved HC, Fuursted K, Storgaard M, Dröse S, Johansen IS, Thorsteinsson K, Kronborg G, Lebech AM, Benfield T. Oral and anal carriage of Streptococcus pneumoniae among sexually active men with HIV who have sex with men. J Infect Dis 2021; 225:1575-1580. [PMID: 34622276 DOI: 10.1093/infdis/jiab512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/04/2021] [Indexed: 11/12/2022] Open
Abstract
People with HIV are at increased risk of pneumococcal disease. We investigate oral and anal carriage rates of Streptococcus pneumoniae by molecular methods among 82 men with HIV who have sex with men (MSM). A questionnaire, oral wash and anal swab samples were obtained at baseline and 12 months. Oral carriage rates were 32.9% (27/82) at baseline and 41.7% (30/72) at follow-up. Anal carriage rates were 2.4% (2/82) at baseline and 2.9% (2/70) at follow-up. Genogroup 24 was predominant. Results suggest high oral carriage rates of S. pneumoniae among MSM living with HIV. A minority were anal carriers.
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Affiliation(s)
- Michaela Tinggaard
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Hans-Christian Slotved
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Kurt Fuursted
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Sandra Dröse
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Denmark
| | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Denmark
| | - Kristina Thorsteinsson
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Gitte Kronborg
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Mette Lebech
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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