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Miguelena Chamorro B, De Luca K, Swaminathan G, Longet S, Mundt E, Paul S. Bordetella bronchiseptica and Bordetella pertussis: Similarities and Differences in Infection, Immuno-Modulation, and Vaccine Considerations. Clin Microbiol Rev 2023; 36:e0016422. [PMID: 37306571 PMCID: PMC10512794 DOI: 10.1128/cmr.00164-22] [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] [Indexed: 06/13/2023] Open
Abstract
Bordetella pertussis and Bordetella bronchiseptica belong to the genus Bordetella, which comprises 14 other species. B. pertussis is responsible for whooping cough in humans, a severe infection in children and less severe or chronic in adults. These infections are restricted to humans and currently increasing worldwide. B. bronchiseptica is involved in diverse respiratory infections in a wide range of mammals. For instance, the canine infectious respiratory disease complex (CIRDC), characterized by a chronic cough in dogs. At the same time, it is increasingly implicated in human infections, while remaining an important pathogen in the veterinary field. Both Bordetella can evade and modulate host immune responses to support their persistence, although it is more pronounced in B. bronchiseptica infection. The protective immune responses elicited by both pathogens are comparable, while there are important characteristics in the mechanisms that differ. However, B. pertussis pathogenesis is more difficult to decipher in animal models than those of B. bronchiseptica because of its restriction to humans. Nevertheless, the licensed vaccines for each Bordetella are different in terms of formulation, route of administration and immune responses induced, with no known cross-reaction between them. Moreover, the target of the mucosal tissues and the induction of long-lasting cellular and humoral responses are required to control and eliminate Bordetella. In addition, the interaction between both veterinary and human fields are essential for the control of this genus, by preventing the infections in animals and the subsequent zoonotic transmission to humans.
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Affiliation(s)
- Beatriz Miguelena Chamorro
- CIRI – Centre International de Recherche en Infectiologie, Team GIMAP (Saint-Etienne), Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR5308, ENS Lyon, UJM, Lyon, France
- Boehringer Ingelheim, Global Innovation, Saint-Priest, France
| | - Karelle De Luca
- Boehringer Ingelheim, Global Innovation, Saint-Priest, France
| | | | - Stéphanie Longet
- CIRI – Centre International de Recherche en Infectiologie, Team GIMAP (Saint-Etienne), Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR5308, ENS Lyon, UJM, Lyon, France
- CIC Inserm 1408 Vaccinology, Saint-Etienne, France
| | - Egbert Mundt
- Boehringer Ingelheim, Global Innovation, Saint-Priest, France
| | - Stéphane Paul
- CIRI – Centre International de Recherche en Infectiologie, Team GIMAP (Saint-Etienne), Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR5308, ENS Lyon, UJM, Lyon, France
- CIC Inserm 1408 Vaccinology, Saint-Etienne, France
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Cimolai N. Non-primate animal models for pertussis: back to the drawing board? Appl Microbiol Biotechnol 2022; 106:1383-1398. [PMID: 35103810 PMCID: PMC8803574 DOI: 10.1007/s00253-022-11798-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/30/2022]
Abstract
Abstract Despite considerable progress in the understanding of clinical pertussis, the contemporary emergence of antimicrobial resistance for Bordetella pertussis and an evolution of concerns with acellular component vaccination have both sparked a renewed interest. Although simian models of infection best correlate with the observed attributes of human infection, several animal models have been used for decades and have positively contributed in many ways to the related science. Nevertheless, there is yet the lack of a reliable small animal model system that mimics the combination of infection genesis, variable upper and lower respiratory infection, systemic effects, infection resolution, and vaccine responses. This narrative review examines the history and attributes of non-primate animal models for pertussis and places context with the current use and needs. Emerging from the latter is the necessity for further such study to better create the optimal model of infection and vaccination with use of current molecular tools and a broader range of animal systems. Key points • Currently used and past non-primate animal models of B. pertussis infection often have unique and focused applications. • A non-primate animal model that consistently mimics human pertussis for the majority of key infection characteristics is lacking. • There remains ample opportunity for an improved non-primate animal model of pertussis with the use of current molecular biology tools and with further exploration of species not previously considered. Graphical abstract ![]()
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Affiliation(s)
- Nevio Cimolai
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada. .,Children's and Women's Health Centre of British Columbia, 4480 Oak Street, Vancouver, B.C., V6H3V4, Canada.
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Guiso N, Soubeyrand B, Macina D. Can vaccines control bacterial virulence and pathogenicity? Bordetella pertussis: the advantage of fitness over virulence. Evol Med Public Health 2022; 10:363-370. [PMID: 36032328 PMCID: PMC9400806 DOI: 10.1093/emph/eoac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022] Open
Abstract
Some vaccines, such as diphtheria toxoid and acellular pertussis vaccines (aPVs), may favor the emergence of less pathogenic strains of the respective bacteria they target. This review discusses the impact of the wide use of aPV on Bordetella pertussis phenotype evolutions and their beneficial consequences in the light of the diphtheria toxoid immunization program experience and structuring evidence review in a causal analysis following Bradford Hill’s causality criteria. All aPVs contain the pertussis toxin (PT), the main virulence factor of B.pertussis, alone or with one adhesin (filamentous hemagglutinin (FHA)), two adhesins (FHA and pertactin (PRN)) or four adhesins (FHA, PRN and two fimbriae (Fim 2/3)). In countries where the coverage of aPVs containing PRN is high, PRN negative B.pertussis isolates are increasing in prevalence, but isolates nonproducing the other antigens are rarely reported. We hypothesize that the selective pressure at play with PRN should exist against all aVP antigens, although detection biases may hinder its detection for other antigens, especially PT. PT being responsible for clinically frank cases of the disease, the opportunity to collect PT negative isolates is far lower than to collect PRN negative isolates which have a limited clinical impact. The replacement of the current B.pertussis by far less pathogenic isolates no longer producing the factors contained in aPVs should be expected as a consequence of the wide aPV use.
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Zhang C, Zong Y, Wang Z, Wang L, Li Y, Yang Y. Risk factors and prediction model of severe pertussis in infants < 12 months of age in Tianjin, China. BMC Infect Dis 2022; 22:24. [PMID: 34983413 PMCID: PMC8725437 DOI: 10.1186/s12879-021-07001-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background To identify risk factors associated with the prognosis of pertussis in infants (< 12 months). Methods A retrospective study on infants hospitalized with pertussis January 2017 to June 2019. The infants were divided into two groups according to the severity of disease: severe pertussis and non-severe pertussis groups. We collected all case data from medical records including socio-demographics, clinical manifestations, and auxiliary examinations. Univariate analysis and Logistic regression were used. Results Finally, a total of 84 infants with severe pertussis and 586 infants with non-severe pertussis were admitted. The data of 75% of the cases (severe pertussis group, n = 63; non-severe pertussis group, n = 189) were randomly selected for univariate and multivariate logistic regression analysis. The results showed rural area [P = 0.002, OR = 6.831, 95% CI (2.013–23.175)], hospital stay (days) [P = 0.002, OR = 1.304, 95% CI (1.107–1.536)], fever [P = 0.040, OR = 2.965, 95% CI (1.050–8.375)], cyanosis [P = 0.008, OR = 3.799, 95% CI (1.419–10.174)], pulmonary rales [P = 0.021, OR = 4.022, 95% CI (1.228–13.168)], breathing heavily [P = 0.001, OR = 58.811, 95% CI (5.503–628.507)] and abnormal liver function [P < 0.001, OR = 9.164, 95% CI (2.840–29.565)] were independent risk factors, and higher birth weight [P = 0.006, OR = 0.380, 95% CI (0.191–0.755)] was protective factor for severe pertussis in infants. The sensitivity and specificity of logistic regression model for remaining 25% data of severe group and common group were 76.2% and 81.0%, respectively, and the consistency rate was 79.8%. Conclusions The findings indicated risk factor prediction models may be useful for the early identification of severe pertussis in infants.
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Affiliation(s)
- Cui Zhang
- Department of Infectious Disease, Tianjin Second People's Hospital, No. 7 Sudinan Road, Nankai District, Tianjin, 300192, China
| | - Yanmei Zong
- Department of Infectious Disease, Tianjin Second People's Hospital, No. 7 Sudinan Road, Nankai District, Tianjin, 300192, China
| | - Zhe Wang
- Department of Infectious Disease, Tianjin Second People's Hospital, No. 7 Sudinan Road, Nankai District, Tianjin, 300192, China
| | - Li Wang
- Department of Pharmacy, Tianjin Second People's Hospital, Tianjin, 300192, China
| | - Ying Li
- Department of Infectious Disease, Tianjin Second People's Hospital, No. 7 Sudinan Road, Nankai District, Tianjin, 300192, China.
| | - Yuejie Yang
- Department of Infectious Disease, Tianjin Second People's Hospital, No. 7 Sudinan Road, Nankai District, Tianjin, 300192, China.
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Kroes MM, Miranda-Bedate A, Hovingh ES, Jacobi R, Schot C, Pupo E, Raeven RHM, van der Ark AAJ, van Putten JPM, de Wit J, Mariman R, Pinelli E. Naturally circulating pertactin-deficient Bordetella pertussis strains induce distinct gene expression and inflammatory signatures in human dendritic cells. Emerg Microbes Infect 2021; 10:1358-1368. [PMID: 34132167 PMCID: PMC8259873 DOI: 10.1080/22221751.2021.1943537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Respiratory infections caused by Bordetella pertussis are reemerging despite high pertussis vaccination coverage. Since the introduction of the acellular pertussis vaccine in the late twentieth century, circulating B. pertussis strains increasingly lack expression of the vaccine component pertactin (Prn). In some countries, up to 90% of the circulating B. pertussis strains are deficient in Prn. To better understand the resurgence of pertussis, we investigated the response of human monocyte-derived dendritic cells (moDCs) to naturally circulating Prn-expressing (Prn-Pos) and Prn-deficient (Prn-Neg) B. pertussis strains from 2016 in the Netherlands. Transcriptome analysis of moDC showed enriched IFNα response-associated gene expression after exposure to Prn-Pos B. pertussis strains, whereas the Prn-Neg strains induced enriched expression of interleukin- and TNF-signaling genes, as well as other genes involved in immune activation. Multiplex immune assays confirmed enhanced proinflammatory cytokine secretion by Prn-Neg stimulated moDC. Comparison of the proteomes from the Prn-Pos and Prn-Neg strains revealed, next to the difference in Prn, differential expression of a number of other proteins including several proteins involved in metabolic processes. Our findings indicate that Prn-deficient B. pertussis strains induce a distinct and stronger immune activation of moDCs than the Prn-Pos strains. These findings highlight the role of pathogen adaptation in the resurgence of pertussis as well as the effects that vaccine pressure can have on a bacterial population.
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Affiliation(s)
- Michiel M Kroes
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands.,Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Alberto Miranda-Bedate
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Elise S Hovingh
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Ronald Jacobi
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Corrie Schot
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Elder Pupo
- Institute for Translational Vaccinology (Intravacc), Bilthoven, Netherlands
| | - René H M Raeven
- Institute for Translational Vaccinology (Intravacc), Bilthoven, Netherlands
| | | | - Jos P M van Putten
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Jelle de Wit
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Rob Mariman
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Elena Pinelli
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
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Solans L, Debrie AS, Coutte L, Locht C. Construction and evaluation of a pertactin-deficient live attenuated pertussis vaccine candidate BPZE1 derivative. Vaccine 2021; 39:2843-2849. [PMID: 33896662 DOI: 10.1016/j.vaccine.2021.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/22/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
Pertussis, mainly caused by Bordetella pertussis, is a severe respiratory disease that can be fatal, especially in young infants. Vaccines, massively implemented since the middle of the last century, have substantially reduced the pertussis incidence, but have not been able to fully control the disease. One of the shortcomings of current pertussis vaccines is their inability to prevent infection by and transmission of B. pertussis, in contrast to immunity following natural infection. We have developed the live attenuated nasal vaccine BPZE1 and have shown that it prevents both disease and B. pertussis infection in preclinical models. This vaccine is now in clinical development. However, the initial clinical studies have suggested that vaccine take is hampered by pre-existing antibodies to pertactin. Here, we have constructed a pertactin-deficient BPZE1 derivative called BPZE1P in order to overcome this limitation. BPZE1P colonized the murine respiratory tract as efficiently as BPZE1 and induced antibodies at levels similar to those elicited by BPZE1. In the presence of pre-existing antibodies induced by acellular pertussis vaccination, BPZE1P colonized the mouse respiratory tract more efficiently than BPZE1. Both vaccines protected equally well the murine lungs and noses from challenge with laboratory and clinical strains of B. pertussis, including pertactin-deficient strains, against which current acellular pertussis vaccines are less efficient. BPZE1P may thus be an interesting alternative to BPZE1 to overcome vaccine take limitations due to pre-existing antibodies to pertactin.
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Affiliation(s)
- Luis Solans
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | - Anne-Sophie Debrie
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | - Loïc Coutte
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France
| | - Camille Locht
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France.
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Zomer A, Otsuka N, Hiramatsu Y, Kamachi K, Nishimura N, Ozaki T, Poolman J, Geurtsen J. Bordetella pertussis population dynamics and phylogeny in Japan after adoption of acellular pertussis vaccines. Microb Genom 2018; 4. [PMID: 29771235 PMCID: PMC5994715 DOI: 10.1099/mgen.0.000180] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Bordetella pertussis, the causative agent of whooping cough, has experienced a resurgence in the past 15 years, despite the existence of both whole-cell and acellular vaccines. Here, we performed whole genome sequencing analysis of 149 clinical strains, provided by the National Institute of Infectious Diseases (NIID), Japan, isolated in 1982–2014, after Japan became the first country to adopt acellular vaccines against B. pertussis. Additionally, we sequenced 39 strains provided by the Konan Kosei Hospital in Aichi prefecture, Japan, isolated in 2008–2013. The genome sequences afforded insight into B. pertussis genome variability and population dynamics in Japan, and revealed that the B. pertussis population in Japan was characterized by two major clades that divided more than 40 years ago. The pertactin gene was disrupted in about 20 % of the 149 NIID isolates, by either a deletion within the signal sequence (ΔSS) or the insertion of IS element IS481 (prn :: IS481). Phylogeny suggests that the parent clones for these isolates originated in Japan. Divergence dating traced the first generation of the pertactin-deficient mutants in Japan to around 1990, and indicated that strains containing the alternative pertactin allele prn2 may have appeared in Japan around 1974. Molecular clock data suggested that observed fluctuations in B. pertussis population size may have coincided with changes in vaccine usage in the country. The continuing failure to eradicate the disease warrants an exploration of novel vaccine compositions.
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Affiliation(s)
- Aldert Zomer
- 1Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Nao Otsuka
- 2Department of Bacteriology II, National Institute of Infectious Diseases, Musashimurayama, Tokyo, Japan
| | - Yukihiro Hiramatsu
- 2Department of Bacteriology II, National Institute of Infectious Diseases, Musashimurayama, Tokyo, Japan.,†Present address: Department of Molecular Bacteriology, Research Institute for Microbial Diseases, Osaka University, Suita, Osaka, Japan
| | - Kazunari Kamachi
- 2Department of Bacteriology II, National Institute of Infectious Diseases, Musashimurayama, Tokyo, Japan
| | - Naoko Nishimura
- 3Department of Pediatrics, Konan Kosei Hospital, Takaya-cho, Konan, Aichi, Japan
| | - Takao Ozaki
- 3Department of Pediatrics, Konan Kosei Hospital, Takaya-cho, Konan, Aichi, Japan
| | - Jan Poolman
- 4Janssen Vaccines and Prevention B.V., Leiden, The Netherlands
| | - Jeroen Geurtsen
- 4Janssen Vaccines and Prevention B.V., Leiden, The Netherlands
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Will we have new pertussis vaccines? Vaccine 2017; 36:5460-5469. [PMID: 29180031 DOI: 10.1016/j.vaccine.2017.11.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/24/2017] [Accepted: 11/16/2017] [Indexed: 12/20/2022]
Abstract
Despite wide vaccination coverage with efficacious vaccines, pertussis is still not under control in any country. Two types of vaccines are available for the primary vaccination series, diphtheria/tetanus/whole-cell pertussis and diphtheria/tetanus/acellular pertussis vaccines, in addition to reduced antigen content vaccines recommended for booster vaccination. Using these vaccines, several strategies are being explored to counter the current pertussis problems, including repeated vaccination, cocoon vaccination and maternal immunization. With the exception of the latter, none have proven their effectiveness, and even maternal vaccination is not expected to ultimately control pertussis. Therefore, new pertussis vaccines are needed, and several candidates are in early pre-clinical development. They include whole-cell vaccines with low endotoxin content, outer membrane vesicles, new formulations, acellular vaccines with new adjuvants or additional antigens and live attenuated vaccines. The most advanced is the live attenuated nasal vaccine BPZE1. It provides strong protection in mice and non-human primates, is safe, even in immune compromised animals, and genetically stable after in vitro and in vivo passages. It also has interesting immunoregulatory properties without being immunosuppressive. It has successfully completed a first-in-man clinical trial, where it was found to be safe, able to transiently colonize the human respiratory tract and to induce immune responses in the colonized subjects. It is now undergoing further clinical development. As it is designed to reduce carriage and transmission of Bordetella pertussis, it may hopefully contribute to the ultimate control of pertussis.
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Stefanelli P, Buttinelli G, Vacca P, Tozzi AE, Midulla F, Carsetti R, Fedele G, Villani A, Concato C. Severe pertussis infection in infants less than 6 months of age: Clinical manifestations and molecular characterization. Hum Vaccin Immunother 2017; 13:1073-1077. [PMID: 28129036 PMCID: PMC5443365 DOI: 10.1080/21645515.2016.1276139] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We conducted a study to determine the main traits of pertussis among unimmunized infants less than 6 months of age. From August 2012 to March 2015, 141 nasopharyngeal aspirates (NPAs) were collected from infants with respiratory symptoms attending 2 major hospitals in Rome. Clinical data were recorded and analyzed. Lab-confirmation was performed by culture and realtime PCR. B. pertussis virulence-associated genes (ptxP, ptxA and prn), together with multilocus variable-number tandem repeat analysis (MLVA), were also investigated by the sequence-based analysis on the DNAs extracted from positive samples. Antibiotic susceptibility with Etest was defined on 18 viable B. pertussis isolates. Samples from 73 infants resulted positives for B. pertussis. The median age of the patients was 45 d (range 7–165); 21 infants were treated with macrolides before hospital admission. Cough was reported for a median of 10 d before admission and 18 d after hospital discharge among infected infants, 84% of whom showed paroxysmal cough. No resistance to macrolides was detected. Molecular analysis identified MT27 as the predominant MLVA profile, combined with ptxP3-ptxA1-prn2 associated virulence genes. Although our data may not be generalized to the whole country, they provide evidence of disease severity among infants not vaccinated against pertussis. Moreover, genetically related B. pertussis strains, comprising allelic variants of virulence associated genes, were identified.
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Affiliation(s)
- Paola Stefanelli
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Gabriele Buttinelli
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Paola Vacca
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Alberto E Tozzi
- b Multifactorial Disease and Complex Phenotype Research Area, Bambino Gesù Children Hospital IRCCS , Rome , Italy
| | - Fabio Midulla
- c Departments of Pediatrics . "Sapienza" University of Rome , Rome , Italy
| | - Rita Carsetti
- d Immunology Unit, Immunology and Pharmacotherapy Area, Bambino Gesù Children Hospital IRCSS , Rome , Italy
| | - Giorgio Fedele
- a Department of Infectious Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Alberto Villani
- e Department of Pediatrics and Infectious Disease , Bambino Gesù Children Hospital IRCSS , Rome , Italy
| | - Carlo Concato
- f Virology Unit, Bambino Gesù Children Hospital IRCCS , Rome , Italy
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