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Trøseid M, Nielsen SD, Vujkovic-Cvijin I. Gut microbiome and cardiometabolic comorbidities in people living with HIV. MICROBIOME 2024; 12:106. [PMID: 38877521 PMCID: PMC11177534 DOI: 10.1186/s40168-024-01815-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/12/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Despite modern antiretroviral therapy (ART), people living with HIV (PLWH) have increased relative risk of inflammatory-driven comorbidities, including cardiovascular disease (CVD). The gut microbiome could be one of several driving factors, along with traditional risk factors and HIV-related risk factors such as coinfections, ART toxicity, and past immunodeficiency. RESULTS PLWH have an altered gut microbiome, even after adjustment for known confounding factors including sexual preference. The HIV-related microbiome has been associated with cardiometabolic comorbidities, and shares features with CVD-related microbiota profiles, in particular reduced capacity for short-chain fatty acid (SCFA) generation. Substantial inter-individual variation has so far been an obstacle for applying microbiota profiles for risk stratification. This review covers updated knowledge and recent advances in our understanding of the gut microbiome and comorbidities in PLWH, with specific focus on cardiometabolic comorbidities and inflammation. It covers a comprehensive overview of HIV-related and comorbidity-related dysbiosis, microbial translocation, and microbiota-derived metabolites. It also contains recent data from studies in PLWH on circulating metabolites related to comorbidities and underlying gut microbiota alterations, including circulating levels of the SCFA propionate, the histidine-analogue imidazole propionate, and the protective metabolite indole-3-propionic acid. CONCLUSIONS Despite recent advances, the gut microbiome and related metabolites are not yet established as biomarkers or therapeutic targets. The review gives directions for future research needed to advance the field into clinical practice, including promises and pitfalls for precision medicine. Video Abstract.
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Affiliation(s)
- Marius Trøseid
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.
- Section for Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Susanne Dam Nielsen
- Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, 2200, Denmark
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen Oe, 2100, Denmark
| | - Ivan Vujkovic-Cvijin
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Karsh Division of Gastroenterology & Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- F. Widjaja Inflammatory Bowel Disease Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Beck HC, Skovgaard AC, Mohammadnejad A, Palstrøm NB, Nielsen PF, Mengel-From J, Hjelmborg J, Rasmussen LM, Soerensen M. A Mass Spectrometry-Based Proteome Study of Twin Pairs Discordant for Incident Acute Myocardial Infarction within Three Years after Blood Sampling Suggests Novel Biomarkers. Int J Mol Sci 2024; 25:2638. [PMID: 38473885 DOI: 10.3390/ijms25052638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/09/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Acute myocardial infarction (AMI) is a major cause of mortality and morbidity worldwide, yet biomarkers for AMI in the short- or medium-term are lacking. We apply the discordant twin pair design, reducing genetic and environmental confounding, by linking nationwide registry data on AMI diagnoses to a survey of 12,349 twins, thereby identifying 39 twin pairs (48-79 years) discordant for their first-ever AMI within three years after blood sampling. Mass spectrometry of blood plasma identified 715 proteins. Among 363 proteins with a call rate > 50%, imputation and stratified Cox regression analysis revealed seven significant proteins (FDR < 0.05): FGD6, MCAM, and PIK3CB reflected an increased level in AMI twins relative to their non-AMI co-twins (HR > 1), while LBP, IGHV3-15, C1RL, and APOC4 reflected a decreased level in AMI twins relative to their non-AMI co-twins (HR < 1). Additional 50 proteins were nominally significant (p < 0.05), and bioinformatics analyses of all 57 proteins revealed biology within hemostasis, coagulation cascades, the immune system, and the extracellular matrix. A protein-protein-interaction network revealed Fibronectin 1 as a central hub. Finally, technical validation confirmed MCAM, LBP, C1RL, and APOC3. We put forward novel biomarkers for incident AMI, a part of the proteome field where markers are surprisingly rare and where additional studies are highly needed.
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Affiliation(s)
- Hans Christian Beck
- Center for Individualized Medicine in Arterial Diseases, Department of Clinical Biochemistry, Odense University Hospital, J. B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Asmus Cosmos Skovgaard
- The Danish Twin Registry and Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
| | - Afsaneh Mohammadnejad
- The Danish Twin Registry and Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
| | - Nicolai Bjødstrup Palstrøm
- Center for Individualized Medicine in Arterial Diseases, Department of Clinical Biochemistry, Odense University Hospital, J. B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Palle Fruekilde Nielsen
- Center for Individualized Medicine in Arterial Diseases, Department of Clinical Biochemistry, Odense University Hospital, J. B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Jonas Mengel-From
- The Danish Twin Registry and Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
| | - Jacob Hjelmborg
- The Danish Twin Registry and Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
| | - Lars Melholt Rasmussen
- Center for Individualized Medicine in Arterial Diseases, Department of Clinical Biochemistry, Odense University Hospital, J. B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Mette Soerensen
- The Danish Twin Registry and Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, J. B. Winsloews Vej 4, 5000 Odense, Denmark
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Hearps AC, Vootukuru N, Ebrahimnezhaddarzi S, Harney BL, Boo I, Nguyen L, Pavlyshyn D, Dietze PM, Drummer HE, Thompson AJ, Jaworowski A, Hellard ME, Sacks-Davis R, Doyle JS. Injecting drug use and hepatitis C virus infection independently increase biomarkers of inflammatory disease risk which are incompletely restored by curative direct-acting antiviral therapy. Front Immunol 2024; 15:1352440. [PMID: 38420130 PMCID: PMC10899672 DOI: 10.3389/fimmu.2024.1352440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024] Open
Abstract
Background Hepatitis C virus (HCV) infections are more prevalent in people who inject drugs (PWID) who often experience additional health risks. HCV induces inflammation and immune alterations that contribute to hepatic and non-hepatic morbidities. It remains unclear whether curative direct acting antiviral (DAA) therapy completely reverses immune alterations in PWID. Methods Plasma biomarkers of immune activation associated with chronic disease risk were measured in HCV-seronegative (n=24) and HCV RNA+ (n=32) PWID at baseline and longitudinally after DAA therapy. Adjusted generalised estimating equations were used to assess longitudinal changes in biomarker levels. Comparisons between community controls (n=29) and HCV-seronegative PWID were made using adjusted multiple regression modelling. Results HCV-seronegative PWID exhibited significantly increased levels of inflammatory biomarkers including soluble (s) TNF-RII, IL-6, sCD14 and sCD163 and the diabetes index HbA1c as compared to community controls. CXCL10, sTNF-RII, vascular cell adhesion molecule-1 and lipopolysaccharide binding protein (LBP) were additionally elevated in PWID with viremic HCV infection as compared to HCV- PWID. Whilst curative DAA therapy reversed some biomarkers, others including LBP and sTNF-RII remained elevated 48 weeks after HCV cure. Conclusion Elevated levels of inflammatory and chronic disease biomarkers in PWID suggest an increased risk of chronic morbidities such as diabetes and cardiovascular disease. HCV infection in PWID poses an additional disease burden, amplified by the incomplete reversal of immune dysfunction following DAA therapy. These findings highlight the need for heightened clinical surveillance of PWID for chronic inflammatory diseases, particularly those with a history of HCV infection.
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Affiliation(s)
- Anna C. Hearps
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
| | - Nikil Vootukuru
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Gastroenterology, Eastern Health and Monash University, Melbourne, VIC, Australia
| | | | - Brendan L. Harney
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Irene Boo
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
| | - Long Nguyen
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
| | - Damian Pavlyshyn
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
| | - Paul M. Dietze
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- National Drug Research Institute, Curtin University, Melbourne, VIC, Australia
| | - Heidi E. Drummer
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
- Department of Microbiology, Monash University, Melbourne, VIC, Australia
| | - Alexander J. Thompson
- Department of Gastroenterology, St Vincent’s Hospital and the University of Melbourne, Melbourne, VIC, Australia
| | - Anthony Jaworowski
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
| | - Margaret E. Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Rachel Sacks-Davis
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Joseph S. Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC, Australia
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Dalli J, Kitch D, O'Brien MP, Hunt PW, Funderburg N, Moisi D, Gupta A, Brown TT, Tien PC, Aberg JA, Shivakoti R. Pro-inflammatory and pro-resolving lipid mediators of inflammation in HIV: effect of aspirin intervention. EBioMedicine 2023; 89:104468. [PMID: 36791659 PMCID: PMC10025757 DOI: 10.1016/j.ebiom.2023.104468] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/25/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Persons with HIV (PWH) have an increased risk of cardiovascular disease (CVD) compared to HIV-seronegative individuals (SN). Inflammation contributes to this risk but the role of lipid mediators, with central roles in inflammation, in HIV infection remain to be established; further aspirin reduces CVD risk in the general population through production of some of these anti-inflammatory lipid mediators, but they have not been studied in PWH. METHODS We evaluated the relationship between plasma lipid mediators (i.e. 50 lipid mediators including classic eicosanoids and specialized pro-resolving mediators (SPMs)) and HIV status; and the impact of aspirin in PWH on regulating these autacoids. Plasma samples were obtained from 110 PWH receiving antiretroviral therapy (ART) from a randomized trial of aspirin (ACTG-A5331) and 107 matched SN samples (MACS-WIHS Combined Cohort). FINDINGS PWH had lower levels of arachidonic acid-derived pro-inflammatory prostaglandins (PGs: PGE2 and PGD2) and thromboxanes (Tx: TxB2), and higher levels of select pro-resolving lipid mediators (e.g. RvD4 and MaR2n-3 DPA) compared to SN. At the interval tested, aspirin intervention was observed to reduced PGs and Tx, and while we did not observe an increase in aspirin triggered mediators, we observed the upregulation of other SPM in aspirin treated PWH, namely MaR2n-3 DPA. INTERPRETATION Together these observations demonstrate that plasma lipid mediators profiles, some with links to systemic inflammation and CVD risk, become altered in PWH. Furthermore, aspirin intervention did not increase levels of aspirin-triggered pro-resolving lipid mediators, consistent with other reports of an impaired aspirin response in PWH. FUNDING NIH.
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Affiliation(s)
- Jesmond Dalli
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Center for Inflammation and Therapeutic Innovation, Queen Mary University of London, London, UK
| | - Douglas Kitch
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, USA
| | | | - Peter W Hunt
- Department of Medicine, University of California, San Francisco School of Medicine, USA and Department of Veterans Affairs Medical Center, San Francisco, USA
| | - Nicholas Funderburg
- Division of Medical Laboratory Science, School of Health and Rehabilitation Sciences, Ohio State University, Columbus, USA
| | - Daniela Moisi
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, USA
| | - Amita Gupta
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Todd T Brown
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Phyllis C Tien
- Department of Medicine, University of California, San Francisco School of Medicine, USA and Department of Veterans Affairs Medical Center, San Francisco, USA
| | - Judith A Aberg
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Rupak Shivakoti
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA.
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The Gut Microbiome, Microbial Metabolites, and Cardiovascular Disease in People Living with HIV. Curr HIV/AIDS Rep 2023; 20:86-99. [PMID: 36708497 DOI: 10.1007/s11904-023-00648-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW To synthesize recent evidence relating the gut microbiome and microbial metabolites to cardiovascular disease (CVD) in people living with HIV (PLWH). RECENT FINDINGS A few cross-sectional studies have reported on the gut microbiome and cardiovascular outcomes in the context of HIV, with no consistent patterns emerging. The largest such study found that gut Fusobacterium was associated with carotid artery plaque. More studies have evaluated microbial metabolite trimethylamine N-oxide with CVD risk in PLWH, but results were inconsistent, with recent prospective analyses showing null effects. Studies of other microbial metabolites are scarce. Microbial translocation biomarkers (e.g., lipopolysaccharide binding protein) have been related to incident CVD in PLWH. Microbial translocation may increase CVD risk in PLWH, but there is insufficient and/or inconsistent evidence regarding specific microbial species and microbial metabolites associated with cardiovascular outcomes in PLWH. Further research is needed in large prospective studies integrating the gut microbiome, microbial translocation, and microbial metabolites with cardiovascular outcomes in PLWH.
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Chammartin F, Darling K, Abela IA, Battegay M, Furrer H, Calmy A, Bernasconi E, Schmid P, Hoffmann M, Bucher HC. CD4:CD8 Ratio and CD8 Cell Count and Their Prognostic Relevance for Coronary Heart Disease Events and Stroke in Antiretroviral Treated Individuals: The Swiss HIV Cohort Study. J Acquir Immune Defic Syndr 2022; 91:508-515. [PMID: 36150371 PMCID: PMC7613804 DOI: 10.1097/qai.0000000000003094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/05/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION HIV infection leads to a persistent expansion of terminally CD8 T cells and CD8 T suppressor cells, a marker of chronic immune activation leading to a low CD4:CD8 ratio that may persist in the presence of potent antiretroviral therapy and regained CD4 helper cells. It remains unclear whether a low CD4:CD8 ratio is associated with cardiovascular diseases. METHODS We conducted an observational cohort study to investigate the association of immune depression and activation as characterized by the proxy of the CD4:CD8 ratio on the hazard of coronary heart disease (CHD) and stroke among treated individuals living with HIV, while accounting for viral load and known risk factors for cardiovascular diseases and exposure to abacavir or protease inhibitors. We used Cox proportional hazard models with time-dependent cumulative and lagged exposures to account for time-evolving risk factors and avoid reverse causality. RESULTS CD4, CD8, and CD4:CD8 immunological markers were not associated with an increased hazard for CHD. CD8 cell count lagged at 12 months above 1000 cells per μL increased the hazard of stroke, after adjusting for sociodemographics, cardiovascular risk factors, and exposure to specific types of antiretroviral drugs. CONCLUSIONS This analysis of treated HIV-positive individuals within a large cohort with long-term follow-up does not provide evidence for a prognostic role of immune dysregulation regarding CHD. However, increased CD8 cell count may be a moderate risk factor for stroke. Early detection and treatment of HIV-positive individuals are crucial for an optimal immune restoration and a limited CD8 cells expansion.
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Affiliation(s)
- Frédérique Chammartin
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), University Hospital Basel, Basel, Switzerland
| | - Katharine Darling
- Division of Infectious Diseases, University Hospital Lausanne (CHUV), Lausanne, Switzerland
| | - Irene A. Abela
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, Zürich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Hygiene, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Berne, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases University Hospital Geneva, Geneva, Switzerland
| | - Enos Bernasconi
- Division of Infectious Diseases Ospedale Regionale Lugano, Lugano, Switzerland
| | - Patrick Schmid
- Division of Infectious Diseases, Cantonal Hospital St. Gallen, St. Gallen, Switzerland; and
| | - Matthias Hoffmann
- Division of Infectious Diseases, Cantonal Hospital St. Gallen, St. Gallen, Switzerland; and
- Department of General Internal Medicine, Infectious Diseases and Hospital Epidemiology, Cantonal Hospital Olten, Switzerland
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), University Hospital Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Hygiene, University Hospital Basel, University of Basel, Basel, Switzerland
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Hearps AC, Angelovich TA, Trevillyan JM, Wong ME, Calmy A, Hoy JF, Jaworowski A. Effect of Rosuvastatin Therapy on Biomarkers of Inflammation and Immune Activation in People With Human Immunodeficiency Virus at Intermediate Cardiovascular Risk. J Infect Dis 2021; 224:667-672. [PMID: 34398237 DOI: 10.1093/infdis/jiaa775] [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: 10/10/2020] [Accepted: 12/16/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Statins may help prevent cardiovascular disease (CVD) in people with human immunodeficiency virus (PWH) with chronic inflammation owing to their pleotropic lipid-lowering and anti-inflammatory properties. METHODS The impact of 48 weeks of rosuvastatin therapy on inflammation and immune activation in a double-blind, placebo-controlled trial in PWH at moderate cardiovascular disease risk was assessed. RESULTS Rosuvastatin did not alter plasma levels of interleukin 6, soluble tumor necrosis factor receptor type 2, CXCL10, soluble CD14, or soluble vascular cellular adhesion molecule 1 (P ≥ .1 for all). Proportions of CD16+ monocyte subsets were increased in PWH receiving rosuvastatin. CONCLUSIONS The potential benefits of statin use in PWH with normal lipid levels requires further clinical outcome research.
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Affiliation(s)
- Anna C Hearps
- Life Sciences Discipline, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Thomas A Angelovich
- Life Sciences Discipline, Burnet Institute, Melbourne, Victoria, Australia.,School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Janine M Trevillyan
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Michelle E Wong
- Life Sciences Discipline, Burnet Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Alexandra Calmy
- Division of Infectious Diseases, HIV/AIDS Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Jennifer F Hoy
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Anthony Jaworowski
- Life Sciences Discipline, Burnet Institute, Melbourne, Victoria, Australia.,Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia.,School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
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