1
|
Hovi M, Roine U, Autti T, Heiskala H, Roine T, Kirjavainen T. Microstructural White Matter Abnormalities in Children and Adolescents With Narcolepsy Type 1. Pediatr Neurol 2024; 153:56-64. [PMID: 38320459 DOI: 10.1016/j.pediatrneurol.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND In 2010, the H1N1 Pandemrix vaccination campaign was followed by a sudden increase in narcolepsy type 1 (NT1). We investigated the brain white matter microstructure in children with onset of NT1 within two years after the Pandemrix vaccination. METHODS We performed diffusion-weighted magnetic resonance imaging (MRI) on 19 children and adolescents with NT1 and 19 healthy controls. Imaging was performed at a median of 4 years after the diagnosis at a median age of 16 years. For the MRI, we used whole-brain tractography and tract-based spatial statistics (TBSS). We compared these results with medical records and questionnaire data. RESULTS Narcoleptic children showed a global decrease in mean, axial, and radial diffusivity and an increase in planarity coefficient in the white matter TBSS skeleton and tractography. These differences were widespread, and there was an increased asymmetry of the mean diffusivity in children with NT1. The global microstructural metrics were reflected in behavior, and especially the axial diffusion levels correlated with anxiety and depression symptoms and social and behavioral problems. CONCLUSIONS In pediatric patients with Pandemrix-associated NT1, several global changes in the brain white matter network skeleton were observed within five years after the onset of NT1. The degree of changes correlates with behavioral problems.
Collapse
Affiliation(s)
- Marita Hovi
- Children's Hospital, and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Pediatric Neurology, Children's Hospital, University of Helsinki and Helsinki, University Hospital, Helsinki, Finland
| | - Ulrika Roine
- Department of Pediatric Neurology, Children's Hospital, University of Helsinki and Helsinki, University Hospital, Helsinki, Finland; HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Taina Autti
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannu Heiskala
- Department of Pediatric Neurology, Children's Hospital, University of Helsinki and Helsinki, University Hospital, Helsinki, Finland
| | - Timo Roine
- HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland; Turku Brain and Mind Center, University of Turku, Turku, Finland
| | - Turkka Kirjavainen
- Children's Hospital, and Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| |
Collapse
|
2
|
Dudley MZ, Gerber JE, Budigan Ni H, Blunt M, Holroyd TA, Carleton BC, Poland GA, Salmon DA. Vaccinomics: A scoping review. Vaccine 2023; 41:2357-2367. [PMID: 36803903 PMCID: PMC10065969 DOI: 10.1016/j.vaccine.2023.02.009] [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: 04/05/2022] [Revised: 12/24/2022] [Accepted: 02/03/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND This scoping review summarizes a key aspect of vaccinomics by collating known associations between heterogeneity in human genetics and vaccine immunogenicity and safety. METHODS We searched PubMed for articles in English using terms covering vaccines routinely recommended to the general US population, their effects, and genetics/genomics. Included studies were controlled and demonstrated statistically significant associations with vaccine immunogenicity or safety. Studies of Pandemrix®, an influenza vaccine previously used in Europe, were also included, due to its widely publicized genetically mediated association with narcolepsy. FINDINGS Of the 2,300 articles manually screened, 214 were included for data extraction. Six included articles examined genetic influences on vaccine safety; the rest examined vaccine immunogenicity. Hepatitis B vaccine immunogenicity was reported in 92 articles and associated with 277 genetic determinants across 117 genes. Thirty-three articles identified 291 genetic determinants across 118 genes associated with measles vaccine immunogenicity, 22 articles identified 311 genetic determinants across 110 genes associated with rubella vaccine immunogenicity, and 25 articles identified 48 genetic determinants across 34 genes associated with influenza vaccine immunogenicity. Other vaccines had fewer than 10 studies each identifying genetic determinants of their immunogenicity. Genetic associations were reported with 4 adverse events following influenza vaccination (narcolepsy, GBS, GCA/PMR, high temperature) and 2 adverse events following measles vaccination (fever, febrile seizure). CONCLUSION This scoping review identified numerous genetic associations with vaccine immunogenicity and several genetic associations with vaccine safety. Most associations were only reported in one study. This illustrates both the potential of and need for investment in vaccinomics. Current research in this field is focused on systems and genetic-based studies designed to identify risk signatures for serious vaccine reactions or diminished vaccine immunogenicity. Such research could bolster our ability to develop safer and more effective vaccines.
Collapse
Affiliation(s)
- Matthew Z Dudley
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Institute for Vaccine Safety, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Jennifer E Gerber
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Survey Research Division, RTI International, Washington, DC, USA
| | - Haley Budigan Ni
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Office of Health Equity, California Department of Public Health, Richmond, CA, USA
| | - Madeleine Blunt
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Taylor A Holroyd
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bruce C Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Pharmaceutical Outcomes Programme, BC Children's Hospital, Vancouver, BC, Canada; BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Gregory A Poland
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA; Mayo Vaccine Research Group, Mayo Clinic, Rochester, MN, USA
| | - Daniel A Salmon
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Institute for Vaccine Safety, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
3
|
Li X, Gao L, Tong X, Chan VK, Chui CS, Lai FT, Wong CK, Wan EY, Chan EW, Lau KK, Lau CS, Wong IC. Autoimmune conditions following mRNA (BNT162b2) and inactivated (CoronaVac) COVID-19 vaccination: A descriptive cohort study among 1.1 million vaccinated people in Hong Kong. J Autoimmun 2022; 130:102830. [PMID: 35461018 PMCID: PMC9008125 DOI: 10.1016/j.jaut.2022.102830] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Concerns regarding the autoimmune safety of COVID-19 vaccines may negatively impact vaccine uptake. We aimed to describe the incidence of autoimmune conditions following BNT162b2 and CoronaVac vaccination and compare these with age-standardized incidence rates in non-vaccinated individuals. METHODS This is a descriptive cohort study conducted in public healthcare service settings. Territory-wide longitudinal electronic medical records of Hong Kong Hospital Authority users (≥16 years) were linked with COVID-19 vaccination records between February 23, 2021 and June 30, 2021. We classified participants into first/second dose BNT162b2 groups, first/second dose CoronaVac groups and non-vaccinated individuals for incidence comparison. The study outcomes include hospitalized autoimmune diseases (16 types of immune-mediated diseases across six body systems) within 28 days after first and second dose of vaccination. Age-standardized incidence rate ratios (IRRs) with exact 95% confidence intervals (CIs) were estimated using Poisson distribution. RESULTS This study included around 3.9 million Hong Kong residents, of which 1,122,793 received at least one dose of vaccine (BNT162b2: 579,998; CoronaVac: 542,795), and 721,588 completed two doses (BNT162b2: 388,881; CoronaVac: 332,707). Within 28 days following vaccination, cumulative incidences for all autoimmune conditions were below 9 per 100,000 persons, for both vaccines and both doses. None of the age-standardized incidence rates were significantly higher than the non-vaccinated individuals, except for an observed increased incidence of hypersomnia following the first dose of BNT162b2 (standardized IRR: 1.47; 95% CI: 1.10-1.94). CONCLUSIONS Autoimmune conditions requiring hospital care are rare following mRNA and inactivated COVID-19 vaccination with similar incidence to non-vaccinated individuals. The association between first dose BNT162b2 vaccination and immune-related sleeping disorders requires further research. Population-based robust safety surveillance is essential to detect rare and unexpected vaccine safety events.
Collapse
Affiliation(s)
- Xue Li
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China
| | - Le Gao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Xinning Tong
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Vivien K.Y. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Celine S.L. Chui
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China,School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Francisco T.T. Lai
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China
| | - Carlos K.H. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Eric Y.F. Wan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China,Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther W.Y. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China
| | - Kui Kai Lau
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, China
| | - Chak Sing Lau
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Ian C.K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China,Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong, China,Research Department of Practice and Policy, School of Pharmacy, University College London, United Kingdom,Expert Committee on Clinical Events Assessment Following COVID-19 Immunization, Department of Health, The Government of the Hong Kong Special Administrative Region, Hong Kong, China,Corresponding author. Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, L2-57, Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong, China
| |
Collapse
|
4
|
Ferguson D, Wrigley S, Purcell E, Keane S, McGinn B, O'Malley S, Lynch B, Crowe C. Single center analysis of patients with H1N1 vaccine-related narcolepsy and sporadic narcolepsy presenting over the same time period. J Clin Sleep Med 2021; 17:885-895. [PMID: 33289477 DOI: 10.5664/jcsm.9052] [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] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES We aimed to describe the clinical features of narcolepsy in patients referred to our sleep center between 2009 and 2016, and to compare these features across age groups and between sporadic vs AS03-adjuvanted H1N1 influenza vaccine-related patients. METHODS This is a retrospective, consecutive study of adult and pediatric narcolepsy patients in the Republic of Ireland. All participants underwent structured assessments, including polysomnography and the Multiple Sleep Latency Test. Brain magnetic resonance imaging, hypocretin levels, and human leukocyte antigen typing were also carried out on the majority of patients. Patients were compared across age groups as well as etiology. RESULTS The conditions of 40 (74%) patients were vaccine-related. The median age was 13.5 years and time from symptom onset to diagnosis was 112 weeks. Median time from vaccination to symptom onset was 26 weeks. In children, hypnogogic hallucinations and sleep paralysis were less frequent than in adults (17% vs 67%, P = .018 and 0% vs 75%, P < .0005). Sleep latency determined by the Multiple Sleep Latency Test was shorter in children than adults (median 1.75 vs 4 minutes, P = .011). Patients with vaccine-related and sporadic narcolepsies had typical clinical presentations. Vaccine-related patients had longer polysomnography latency (median 10.5 vs 5 minutes, P = .043), longer stage N2 sleep (209.6 ± 44.6 vs 182.3 ± 34.2 minutes, P = .042), and a trend toward longer total sleep times (P = .09). No differences were noted in relation to Multiple Sleep Latency Test, hypocretin, human leukocyte antigen typing, and magnetic resonance imaging. CONCLUSIONS Results show that vaccine-related patients greatly outnumbered sporadic patients during the study period and suggest that sporadic and vaccine-related narcolepsy are clinically similar entities.
Collapse
Affiliation(s)
- Damien Ferguson
- Neurology Department, St. Vincent's University Hospital, Dublin, Ireland
| | - Sarah Wrigley
- Neurology Department, St. Vincent's University Hospital, Dublin, Ireland
| | | | - Sarah Keane
- Sleep Clinic, Mater Private Hospital, Dublin, Ireland
| | - Ben McGinn
- Sleep Clinic, Mater Private Hospital, Dublin, Ireland
| | - Siobhan O'Malley
- Department of Neurology, Children's Health Ireland at Temple St, Dublin, Ireland
| | - Bryan Lynch
- Department of Neurology, Children's Health Ireland at Temple St, Dublin, Ireland
| | | |
Collapse
|
5
|
Adjuvanted AH1N1 influenza vaccine precipitating the appearance of narcolepsy. VACUNAS (ENGLISH EDITION) 2021. [PMCID: PMC8192301 DOI: 10.1016/j.vacune.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
6
|
Luo G, Yogeshwar S, Lin L, Mignot EJM. T cell reactivity to regulatory factor X4 in type 1 narcolepsy. Sci Rep 2021; 11:7841. [PMID: 33837283 PMCID: PMC8035403 DOI: 10.1038/s41598-021-87481-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/23/2021] [Indexed: 11/11/2022] Open
Abstract
Type 1 narcolepsy is strongly (98%) associated with human leukocyte antigen (HLA) class II DQA1*01:02/DQB1*06:02 (DQ0602) and highly associated with T cell receptor (TCR) alpha locus polymorphism as well as other immune regulatory loci. Increased incidence of narcolepsy was detected following the 2009 H1N1 pandemic and linked to Pandemrix vaccination, strongly supporting that narcolepsy is an autoimmune disorder. Although recent results suggest CD4+ T cell reactivity to neuropeptide hypocretin/orexin and cross-reactive flu peptide is involved, identification of other autoantigens has remained elusive. Here we study whether autoimmunity directed against Regulatory Factor X4 (RFX4), a protein co-localized with hypocretin, is involved in some cases of narcolepsy. Studying human serum, we found that autoantibodies against RFX4 were rare. Using RFX4 peptides bound to DQ0602 tetramers, antigen RFX4-86, -95, and -60 specific human CD4+ T cells were detected in 4/10 patients and 2 unaffected siblings, but not in others. Following culture with each cognate peptide, enriched autoreactive TCRαβ clones were isolated by single-cell sorting and TCR sequenced. Homologous clones bearing TRBV4-2 and recognizing RFX4-86 in patients and one twin control of patient were identified. These results suggest the involvement of RFX4 CD4+ T cell autoreactivity in some cases of narcolepsy, but also in healthy donors.
Collapse
Affiliation(s)
- Guo Luo
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Selina Yogeshwar
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Biosciences, Department of Cell and Developmental Biology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Ling Lin
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Emmanuel Jean-Marie Mignot
- Department of Psychiatry and Behavioral Sciences, Stanford University Center for Sleep Sciences, Stanford University School of Medicine, Palo Alto, CA, USA.
| |
Collapse
|
7
|
Quaedackers L, Pillen S, Overeem S. Recognizing the Symptom Spectrum of Narcolepsy to Improve Timely Diagnosis: A Narrative Review. Nat Sci Sleep 2021; 13:1083-1096. [PMID: 34262379 PMCID: PMC8273742 DOI: 10.2147/nss.s278046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022] Open
Abstract
Narcolepsy is a chronic sleep disorder with a strong negative impact on quality of life, especially when untreated. Diagnostic delay is a persistent problem, with obvious detrimental effects on patients. A diagnosis of narcolepsy may be delayed because of its broad symptom presentation which is much more encompassing than the classical "tetrad" of sleepiness, cataplexy, hallucinations, and sleep paralysis. Furthermore, symptoms can vary over time. Presentation of symptoms can also be markedly different between children and adults. Finally, common sleep-related comorbidities increase the risk of narcolepsy being masked by overlapping symptoms or treatment. In this review, we provide a detailed description of the broad and dynamic symptom spectrum of narcolepsy, with specific attention to the different manifestations in both adults and children. The overarching goal is to help not only sleep specialists, but general practitioners, pediatricians, and other caregivers with early recognition and prompt diagnosis of this severe but treatable disorder.
Collapse
Affiliation(s)
| | - Sigrid Pillen
- Sleep Medicine Center Kempenhaeghe, Heeze, the Netherlands
| | - Sebastiaan Overeem
- Biomedical Diagnostics Laboratory, Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| |
Collapse
|
8
|
Wasling HB, Bornstein A, Wasling P. Quality of life and procrastination in post-H1N1 narcolepsy, sporadic narcolepsy and idiopathic hypersomnia, a Swedish cross-sectional study. Sleep Med 2020; 76:104-112. [PMID: 33152582 DOI: 10.1016/j.sleep.2020.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/10/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE/BACKGROUND A cross-sectional study of health-related quality of life (HRQoL), procrastination and the relation to sleepiness, depression and fatigue in post-H1N1 narcolepsy type 1 (NT1), sporadic NT1 and idiopathic hypersomnia (IH). PATIENTS/METHODS Participants with NT1 and IH were enrolled from the Department of Neurology, Sahlgrenska University Hospital in Gothenburg (Sweden). All participants completed questionnaires about medication, employment, studies, transfer income, sleepiness, HRQoL, depression, fatigue and three questionnaires for procrastination. RESULTS Post-H1N1, sporadic NT1 and IH all scored higher than healthy controls on Epworth Sleepiness Scale (ESS), Patient Health Questionnaire (PHQ-9) and Fatigue Severity Scale (FSS), whereas EQ-5D-5L index and VAS was lower than for healthy individuals, but with no difference between groups. Post-H1N1 NT1 had a larger proportion of participants prescribed with sodium oxybate (44% vs. 9%, p = 0.003) and dexamphetamine (62% vs. 17%, p = 0.03) compared to sporadic NT1. The latter also in significantly higher doses than in sporadic NT1 (46 ± 12 vs. 25 ± 10 and 47.5 ± 21 mg, p < 0.0001). Post-H1N1 NT1 also had significantly higher scores on Pure Procrastination Scale (PPS), Irrational Procrastination Scale (IPS) and Susceptibility to Temptation Scale (STS), indicating a higher degree of procrastination. Multivariate analysis showed that depression, and to some extent fatigue, were predictors in NT1 for both HRQoL and procrastination. CONCLUSIONS The results show that health-related quality of life is impaired and tendency to procrastinate is higher in patients suffering from NT1 and both attributes can in part be explained by depressive symptoms. These findings highlight the impact of symptoms other than sleep and wakefulness regulation in patients with NT1.
Collapse
Affiliation(s)
- Helena Backlund Wasling
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Axel Bornstein
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Pontus Wasling
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| |
Collapse
|
9
|
Lacroix C, Mallaret M, Jonville-Bera AP. Pharmacovigilance and drug-induced rare diseases: Strengths of the French Network of Regional Pharmacovigilance Centres. Therapie 2020; 75:207-213. [DOI: 10.1016/j.therap.2020.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/15/2019] [Indexed: 01/24/2023]
|
10
|
Sullivan SG, Price OH, Regan AK. Burden, effectiveness and safety of influenza vaccines in elderly, paediatric and pregnant populations. Ther Adv Vaccines Immunother 2019; 7:2515135519826481. [PMID: 30793097 PMCID: PMC6376509 DOI: 10.1177/2515135519826481] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/20/2018] [Indexed: 11/17/2022] Open
Abstract
Vaccination is the most practical means available for preventing influenza. Influenza vaccines require frequent updates to keep pace with antigenic drift of the virus, and the effectiveness, and sometimes the safety, of the vaccine can therefore vary from season to season. Three key populations that the World Health Organization recommends should be prioritized for influenza vaccination are pregnant women, children younger than 5 years of age and the elderly. This review discusses the burden of influenza and the safety and effectiveness profile of influenza vaccines recommended for these groups.
Collapse
Affiliation(s)
- Sheena G. Sullivan
- WHO Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia
- School of Population and Global Health, University of Melbourne, Australia Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Olivia H. Price
- WHO Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Annette K. Regan
- School of Public Health, Texas A&M University, College Station, TX, United States; School of Public Health, Curtin University, Perth, Western Australia, Australia, and Wesfamers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Crawley, Western Australia, Australia
| |
Collapse
|
11
|
Sasaki E, Momose H, Hiradate Y, Mizukami T, Hamaguchi I. Establishment of a novel safety assessment method for vaccine adjuvant development. Vaccine 2018; 36:7112-7118. [PMID: 30318166 DOI: 10.1016/j.vaccine.2018.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/09/2018] [Accepted: 09/29/2018] [Indexed: 12/27/2022]
Abstract
Vaccines effectively prevent infectious diseases. Many types of vaccines against various pathogens that threaten humans are currently in widespread use. Recently, adjuvant adaptation has been attempted to activate innate immunity to enhance the effectiveness of vaccines. The effectiveness of adjuvants for vaccinations has been demonstrated in many animal models and clinical trials. Although a highly potent adjuvant tends to have high effectiveness, it also has the potential to increase the risk of side effects such as pain, edema, and fever. Indeed, highly effective adjuvants, such as poly(I:C), have not been clinically applied due to their high risks of toxicity in humans. Therefore, the task in the field of adjuvant development is to clinically apply highly effective and non- or low-toxic adjuvant-containing vaccines. To resolve this issue, it is essential to ensure a low risk of side effects and the high efficacy of an adjuvant in the early developmental phases. This review summarizes the theory and history of the current safety assessment methods for adjuvants, using the inactivated influenza vaccine as a model. Our novel method was developed as a system to judge the safety of a candidate compound using biomarkers identified by genomic technology and statistical tools. A systematic safety assessment tool for adjuvants would be of great use for predicting toxicity during novel adjuvant development, screening, and quality control.
Collapse
Affiliation(s)
- Eita Sasaki
- Department of Safety Research on Blood and Biological Products, National Institute of Infectious Diseases, 4-7-1 Gakuen, Musashi-Murayama, Tokyo 208-0011, Japan
| | - Haruka Momose
- Department of Safety Research on Blood and Biological Products, National Institute of Infectious Diseases, 4-7-1 Gakuen, Musashi-Murayama, Tokyo 208-0011, Japan
| | - Yuki Hiradate
- Department of Safety Research on Blood and Biological Products, National Institute of Infectious Diseases, 4-7-1 Gakuen, Musashi-Murayama, Tokyo 208-0011, Japan
| | - Takuo Mizukami
- Department of Safety Research on Blood and Biological Products, National Institute of Infectious Diseases, 4-7-1 Gakuen, Musashi-Murayama, Tokyo 208-0011, Japan
| | - Isao Hamaguchi
- Department of Safety Research on Blood and Biological Products, National Institute of Infectious Diseases, 4-7-1 Gakuen, Musashi-Murayama, Tokyo 208-0011, Japan.
| |
Collapse
|
12
|
Dhanju S, Al-Saleh S, Amin R, Weiss SK, Zweerink A, Toulany A, Murray BJ, Narang I. A retrospective analysis of clinical characteristics of childhood narcolepsy. Paediatr Child Health 2018; 23:e95-e101. [PMID: 30455579 PMCID: PMC6234419 DOI: 10.1093/pch/pxx205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AIM Narcolepsy, encompassing excessive daytime sleepiness (EDS), cataplexy, sleep paralysis and hypnogogic hallucinations, was previously considered rare in childhood. Recently, cases of childhood narcolepsy have increased significantly and the reasons for this may include the increasing awareness of narcolepsy as well as the H1N1 vaccination. The aim of this study was to describe the clinical characteristics of childhood narcolepsy, specifically focusing on cataplexy subtypes that may facilitate early recognition of narcolepsy. METHODS We retrospectively reviewed and analyzed the medical records of 33 children diagnosed with narcolepsy at the Hospital for Sick Children, in Toronto, Ontario. All patients were seen prior to 18 years of age and symptoms were self-reported by parents and/or children themselves. RESULTS At presentation, 32 of 33 children reported EDS and 28 of 33 reported cataplexy. Among the 28 patients with cataplexy, 18 of 28 reported cataplexy referred to as 'cataplectic facies' (e.g., facial hypotonia and/or tongue protrusion) while 10 of 28 patients reported characteristic cataplexy, defined as bilateral loss of muscle tone. Children with cataplectic facies reported higher BMI z-scores compared to those with characteristic cataplexy, 1.8 and 0.8, respectively. Children with cataplectic facies also tended to be younger than those with characteristic cataplexy, 9.2 and 11.8 years of age, respectively. Cataplectic facies appear to be related to narcolepsy close to disease onset. CONCLUSIONS Children, especially young, obese children, presenting with a history of EDS with associated facial hypotonia or tongue protrusion raises the index of suspicion of narcolepsy and should prompt a referral to a specialized sleep facility to establish the diagnosis.
Collapse
Affiliation(s)
- Simranpal Dhanju
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
- University of Toronto, Toronto, Ontario
| | - Reshma Amin
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
- University of Toronto, Toronto, Ontario
| | - Shelly K Weiss
- University of Toronto, Toronto, Ontario
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario
| | - Allison Zweerink
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Alene Toulany
- University of Toronto, Toronto, Ontario
- Division of Adolescent Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Brian J Murray
- University of Toronto, Toronto, Ontario
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Indra Narang
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
- University of Toronto, Toronto, Ontario
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW After the connection between AS03-adjuvanted pandemic H1N1 vaccine Pandemrix and narcolepsy was recognized in 2010, research on narcolepsy has been more intensive than ever before. The purpose of this review is to provide the reader with current concepts and recent findings on the Pandemrix-associated narcolepsy. RECENT FINDINGS After the Pandemrix vaccination campaign in 2009-2010, the risk of narcolepsy was increased 5- to 14-fold in children and adolescents and 2- to 7-fold in adults. According to observational studies, the risk of narcolepsy was elevated for 2 years after the Pandemrix vaccination. Some confounding factors and potential diagnostic biases may influence the observed narcolepsy risk in some studies, but it is unlikely that they would explain the clearly increased incidence in all the countries where Pandemrix was used. An increased risk of narcolepsy after natural H1N1 infection was reported from China, where pandemic influenza vaccination was not used. There is more and more evidence that narcolepsy is an autoimmune disease. All Pandemrix-associated narcolepsy cases have been positive for HLA class II DQB1*06:02 and novel predisposing genetic factors directly linking to the immune system have been identified. Even though recent studies have identified autoantibodies against multiple neuronal structures and other host proteins and peptides, no specific autoantigens that would explain the disease mechanism in narcolepsy have been identified thus far. There was a marked increase in the incidence of narcolepsy after Pandemrix vaccination, especially in adolescents, but also in young adults and younger children. All vaccine-related cases were of narcolepsy type 1 characterized by hypocretin deficiency in the central nervous system. The disease phenotype and the severity of symptoms varied considerably in children and adolescents suffering from Pandemrix-associated narcolepsy, but they were indistinguishable from the symptoms of idiopathic narcolepsy. Narcolepsy type 1 is most likely an autoimmune disease, but the mechanisms have remained elusive.
Collapse
|
14
|
|
15
|
Talaat KR, Halsey NA, Cox AB, Coles CL, Durbin AP, Ramakrishnan A, Bream JH. Rapid changes in serum cytokines and chemokines in response to inactivated influenza vaccination. Influenza Other Respir Viruses 2018; 12:202-210. [PMID: 28991404 PMCID: PMC5820426 DOI: 10.1111/irv.12509] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The timing of host cytokine responses to influenza vaccination is poorly understood. OBJECTIVES We examined serum cytokine kinetics following inactivated trivalent influenza vaccine (TIV) to better understand potential relationships between markers of inflammation and TIV-related side effects. PATIENTS/METHODS Twenty healthy adult subjects received TIV. Cytokines/chemokines were assessed in intervals from 3 hours to 14 days. Antibody titers were measured at baseline and Day 14. RESULTS Serum cytokine responses to TIV were evident as early as 3 hours post-immunization. Compared to baseline, IFN-γ and IP-10 were significantly elevated 7 hours after TIV administration. Both remained elevated and peaked between 16 and 24 hours before returning to baseline by 44 hours post-vaccination. Although IL-8 levels were variable between subjects during the first 24 hours after TIV, by 44 hours, IL-8 was significantly lower compared to baseline. Interestingly, IL-8 levels remained significantly lower for up to 2 weeks after receiving TIV. Fifteen of 20 subjects reported mild adverse events. The one subject who reported moderate myalgias and injection site pain after vaccination displayed a distinctive, early cytokine response profile which included IL-6, IL-2, IL-8, IP-10, MCP-1, TNF-α, TARC, and MCP-4. CONCLUSIONS Serum cytokines changed rapidly following TIV and generally peaked at 24 hours. Trivalent influenza vaccine-induced reductions in IL-8 occurred later (44 hours) and were sustained for 2 weeks. An outlier response coincided with the only moderate side effects to the vaccine. These data suggest that early cytokine/chemokine responses may provide additional insight into the pathogenesis of adverse events and immune reactivity to vaccination.
Collapse
Affiliation(s)
- Kawsar R. Talaat
- Center for Immunization Research (CIR)Johns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Institute for Vaccine SafetyDepartment of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Neal A. Halsey
- Institute for Vaccine SafetyDepartment of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Amber B. Cox
- Center for Immunization Research (CIR)Johns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Christian L. Coles
- Infectious Disease Clinical Research ProgramUniformed Services University of the HealthBethesdaMDUSA
| | - Anna P. Durbin
- Center for Immunization Research (CIR)Johns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Amritha Ramakrishnan
- Department of Molecular Microbiology and ImmunologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Jay H. Bream
- Department of Molecular Microbiology and ImmunologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| |
Collapse
|
16
|
Wilkins AL, Kazmin D, Napolitani G, Clutterbuck EA, Pulendran B, Siegrist CA, Pollard AJ. AS03- and MF59-Adjuvanted Influenza Vaccines in Children. Front Immunol 2017; 8:1760. [PMID: 29326687 PMCID: PMC5733358 DOI: 10.3389/fimmu.2017.01760] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 11/27/2017] [Indexed: 12/28/2022] Open
Abstract
Influenza is a major cause of respiratory disease leading to hospitalization in young children. However, seasonal trivalent influenza vaccines (TIVs) have been shown to be ineffective and poorly immunogenic in this population. The development of live-attenuated influenza vaccines and adjuvanted vaccines are important advances in the prevention of influenza in young children. The oil-in-water emulsions MF59 and adjuvant systems 03 (AS03) have been used as adjuvants in both seasonal adjuvanted trivalent influenza vaccines (ATIVs) and pandemic monovalent influenza vaccines. Compared with non-adjuvanted vaccine responses, these vaccines induce a more robust and persistent antibody response for both homologous and heterologous influenza strains in infants and young children. Evidence of a significant improvement in vaccine efficacy with these adjuvanted vaccines resulted in the use of the monovalent (A/H1N1) AS03-adjuvanted vaccine in children in the 2009 influenza pandemic and the licensure of the seasonal MF59 ATIV for children aged 6 months to 2 years in Canada. The mechanism of action of MF59 and AS03 remains unclear. Adjuvants such as MF59 induce proinflammatory cytokines and chemokines, including CXCL10, but independently of type-1 interferon. This proinflammatory response is associated with improved recruitment, activation and maturation of antigen presenting cells at the injection site. In young children MF59 ATIV produced more homogenous and robust transcriptional responses, more similar to adult-like patterns, than did TIV. Early gene signatures characteristic of the innate immune response, which correlated with antibody titers were also identified. Differences were detected when comparing child and adult responses including opposite trends in gene set enrichment at day 3 postvaccination and, unlike adult data, a lack of correlation between magnitude of plasmablast response at day 7 and antibody titers at day 28 in children. These insights show the utility of novel approaches in understanding new adjuvants and their importance for developing improved influenza vaccines for children.
Collapse
Affiliation(s)
| | - Dmitri Kazmin
- Emory Vaccine Center, Emory University, Atlanta, GA, United States
| | - Giorgio Napolitani
- Medical Research Council (MRC), Human Immunology Unit, University of Oxford, Oxford, United Kingdom
| | - Elizabeth A. Clutterbuck
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, The NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Bali Pulendran
- Emory Vaccine Center, Emory University, Atlanta, GA, United States
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, United States
- Department of Pathology, and Microbiology & Immunology, Stanford University, Stanford, CA, United States
- Institute for Immunology, Transplantation and Infection, Stanford University, Stanford, CA, United States
| | | | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, The NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| |
Collapse
|
17
|
Absence of anti-hypocretin receptor 2 autoantibodies in post pandemrix narcolepsy cases. PLoS One 2017; 12:e0187305. [PMID: 29220370 PMCID: PMC5722318 DOI: 10.1371/journal.pone.0187305] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 10/17/2017] [Indexed: 12/11/2022] Open
Abstract
Background A recent publication suggested molecular mimicry of a nucleoprotein (NP) sequence from A/Puerto Rico/8/1934 (PR8) strain, the backbone used in the construction of the reassortant strain X-179A that was used in Pandemrix® vaccine, and reported on anti-hypocretin (HCRT) receptor 2 (anti-HCRTR2) autoantibodies in narcolepsy, mostly in post Pandemrix® narcolepsy cases (17 of 20 sera). In this study, we re-examined this hypothesis through mass spectrometry (MS) characterization of Pandemrix®, and two other pandemic H1N1 (pH1N1)-2009 vaccines, Arepanrix® and Focetria®, and analyzed anti-HCRTR2 autoantibodies in narcolepsy patients and controls using three independent strategies. Methods MS characterization of Pandemrix® (2 batches), Arepanrix® (4 batches) and Focetria® (1 batch) was conducted with mapping of NP 116I or 116M spectrogram. Two sets of narcolepsy cases and controls were used: 40 post Pandemrix® narcolepsy (PP-N) cases and 18 age-matched post Pandemrix® controls (PP-C), and 48 recent (≤6 months) early onset narcolepsy (EO-N) cases and 70 age-matched other controls (O-C). Anti-HCRTR2 autoantibodies were detected using three strategies: (1) Human embryonic kidney (HEK) 293T cells with transient expression of HCRTR2 were stained with human sera and then analyzed by flow cytometer; (2) In vitro translation of [35S]-radiolabelled HCRTR2 was incubated with human sera and immune complexes of autoantibody and [35S]-radiolabelled HCRTR2 were quantified using a radioligand-binding assay; (3) Optical density (OD) at 450 nm (OD450) of human serum immunoglobulin G (IgG) binding to HCRTR2 stably expressed in Chinese hamster ovary (CHO)-K1 cell line was measured using an in-cell enzyme-linked immunosorbent assay (ELISA). Results NP 116M mutations were predominantly present in all batches of Pandemrix®, Arepanrix® and Focetria®. The wild-type NP109-123 (ILYDKEEIRRIWRQA), a mimic to HCRTR234-45 (YDDEEFLRYLWR), was not found to bind to DQ0602. Three or four subjects were found positive for anti-HCRTR2 autoantibodies using two strategies or the third one, respectively. None of the post Pandemrix® narcolepsy cases (0 of 40 sera) was found positive with all three strategies. Conclusion Anti-HCRTR2 autoantibody is not a significant biological feature of narcolepsy or of post Pandemrix® autoimmune responses.
Collapse
|
18
|
Influenza vaccine use to protect healthy children: A debated topic. Vaccine 2017; 36:5391-5396. [PMID: 28928077 DOI: 10.1016/j.vaccine.2017.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 08/19/2017] [Accepted: 09/01/2017] [Indexed: 11/20/2022]
Abstract
At the beginning of this century, a number of studies suggested that in healthy children, particularly those <2years of age, influenza could have a serious and complicated course, as it frequently led to hospitalization and sometimes, albeit rarely, to death. Moreover, pre-schoolers and school-age children were found to be among the most important causes of influenza transmission to the community, as they shed the virus for a longer time than adults and had frequent contact with greater numbers of individuals through day-care and school. These findings led a number of health authorities to modify the official recommendations regarding the use of influenza vaccine in healthy children. Several factors seem to indicate that vaccination against influenza in healthy children of any age and in pregnant women could be effective in preventing the disease in the entire paediatric population and in providing herd immunity in adults and old people as well. The direct advantages of the vaccine seem greater in younger subjects, particularly those <2-3years of age. Vaccination of older children is considered effective by most experts, but high vaccination coverage of these subjects has been difficult to attain. Similar difficulties have been identified for the vaccination of pregnant women. These challenges can be overcome, at least in part, by appropriate information and accurate evaluations of available data. In addition, further studies specifically designed to clarify unresolved problems regarding vaccine use in paediatric and pregnant populations are needed to convince reluctant health authorities. More effective vaccines for younger children as well as improved availability of data regarding the optimal time period for vaccine administration in pregnant women appear relevant in this regard.
Collapse
|
19
|
Sarkanen TO, Alakuijala APE, Dauvilliers YA, Partinen MM. Incidence of narcolepsy after H1N1 influenza and vaccinations: Systematic review and meta-analysis. Sleep Med Rev 2017; 38:177-186. [PMID: 28847694 DOI: 10.1016/j.smrv.2017.06.006] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 05/22/2017] [Accepted: 06/14/2017] [Indexed: 11/18/2022]
Abstract
An increased incidence of narcolepsy was seen in many countries after the pandemic H1N1 influenza vaccination campaign in 2009-2010. The H1N1 vaccine - narcolepsy connection is based on observational studies that are prone to various biases, e.g., confounding by H1N1 infection, and ascertainment, recall and selection biases. A direct pathogenic link has, however, remained elusive. We conducted a systematic review and meta-analysis to analyze the magnitude of H1N1 vaccination related risk and to examine if there was any association with H1N1 infection itself. We searched all articles from PubMed, Web of Science and Scopus, and other relevant sources reporting the incidence and risk of post-vaccine narcolepsy. In our paper, we show that the risk appears to be limited to only one vaccine (Pandemrix®). During the first year after vaccination, the relative risk of narcolepsy was increased 5 to 14-fold in children and adolescents and 2 to 7-fold in adults. The vaccine attributable risk in children and adolescents was around 1 per 18,400 vaccine doses. Studies from Finland and Sweden also appear to demonstrate an extended risk of narcolepsy into the second year following vaccination, but such conclusions should be interpreted with a word of caution due to possible biases. Benefits of immunization outweigh the risk of vaccination-associated narcolepsy, which remains a rare disease.
Collapse
Affiliation(s)
- Tomi O Sarkanen
- Central Finland Central Hospital, Department of Neurology, Jyväskylä, Finland; University of Helsinki, Department of Neurological Sciences, Helsinki, Finland.
| | - Anniina P E Alakuijala
- University of Helsinki, Department of Neurological Sciences, Helsinki, Finland; HUS Medical Imaging Center, Helsinki University Central Hospital, Department of Clinical Neurophysiology, Finland
| | - Yves A Dauvilliers
- Gui-de-Chauliac Hospital, CHU Montpellier, Inserm, U1061, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic hypersomnia and Kleine-Levin Syndrome, Sleep Disorders Center, France
| | - Markku M Partinen
- University of Helsinki, Department of Neurological Sciences, Helsinki, Finland; Helsinki Sleep Clinic, Vitalmed Research Centre, Finland
| |
Collapse
|
20
|
Oberle D, Pavel J, Mayer G, Geisler P, Keller-Stanislawski B. Retrospective multicenter matched case-control study on the risk factors for narcolepsy with special focus on vaccinations (including pandemic influenza vaccination) and infections in Germany. Sleep Med 2017; 34:71-83. [PMID: 28522102 DOI: 10.1016/j.sleep.2017.02.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 01/23/2017] [Accepted: 02/14/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Studies associate pandemic influenza vaccination with narcolepsy. In Germany, a retrospective, multicenter, matched case-control study was performed to identify risk factors for narcolepsy, particularly regarding vaccinations (seasonal and pandemic influenza vaccination) and infections (seasonal and pandemic influenza) and to quantify the detected risks. METHODS Patients with excessive daytime sleepiness who had been referred to a sleep center between April 2009 and December 2012 for multiple sleep latency test (MSLT) were eligible. Case report forms were validated according to the criteria for narcolepsy defined by the Brighton Collaboration (BC). Confirmed cases of narcolepsy (BC level of diagnostic certainty 1-4a) were matched with population-based controls by year of birth, gender, and place of residence. A second control group was established including patients in whom narcolepsy was definitely excluded (test-negative controls). RESULTS A total of 103 validated cases of narcolepsy were matched with 264 population-based controls. The second control group included 29 test-negative controls. A significantly increased odd ratio (OR) to develop narcolepsy (crude OR [cOR] = 3.9, 95% confidence interval [CI] = 1.8-8.5; adjusted OR [aOR] = 4.5, 95% CI = 2.0-9.9) was detected in individuals immunized with pandemic influenza A/H1N1/v vaccine prior to symptoms onset as compared to nonvaccinated individuals. Using test-negative controls, in individuals immunized with pandemic influenza A/H1N1/v vaccine prior to symptoms onset, a nonsignificantly increased OR of narcolepsy was detected when compared to nonvaccinated individuals (whole study population, BC levels 1-4a: cOR = 1.9, 95% CI = 0.5-6.9; aOR = 1.8, 95% CI = 0.3-10.1). CONCLUSIONS The findings of this study support an increased risk for narcolepsy after immunization with pandemic influenza A/H1N1/v vaccine.
Collapse
Affiliation(s)
- Doris Oberle
- Department Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany.
| | - Jutta Pavel
- Department Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | - Geert Mayer
- Hephata-Klinik, Schlafzentrum, Schwalmstadt-Treysa, Germany
| | - Peter Geisler
- Sleep Disorders Center, Department of Psychiatry, University of Regensburg, Regensburg, Germany
| | - Brigitte Keller-Stanislawski
- Department Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Germany
| | | |
Collapse
|
21
|
Ahmed SS, Steinman L. Narcolepsy and influenza vaccination-induced autoimmunity. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:25. [PMID: 28164110 PMCID: PMC5253292 DOI: 10.21037/atm.2016.12.63] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 12/01/2016] [Indexed: 11/06/2022]
Affiliation(s)
- S. Sohail Ahmed
- Immunology, Inflammation and Infectious Diseases, Roche Pharma Research & Early Development, Basel 4070, Switzerland
| | - Lawrence Steinman
- Neurology and Neuroscience, Stanford University School of Medicine, Stanford, CA 94305, USA
| |
Collapse
|
22
|
Shah RR, Hassett KJ, Brito LA. Overview of Vaccine Adjuvants: Introduction, History, and Current Status. Methods Mol Biol 2017; 1494:1-13. [PMID: 27718182 DOI: 10.1007/978-1-4939-6445-1_1] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Adjuvants are included in sub-unit or recombinant vaccines to enhance the potency of poorly immunogenic antigens. Adjuvant discovery is as complex as it is a multidiscplinary intersection of formulation science, immunology, toxicology, and biology. Adjuvants such as alum, which have been in use for the past 90 years, have illustrated that adjuvant research is a methodical process. As science advances, new analytical tools are developed which allows us to delve deeper into the various mechanisms that generates a potent immune response. Additionally, these new techniques help the field learn about our existing vaccines and what makes them safe, and effective, allowing us to leverage that in the next generation of vaccines. Our goal in this chapter is to define the concept, need, and mechanism of adjuvants in the vaccine field while describing its history, present use, and future prospects. More details on individual adjuvants and their formulation, development, mechanism, and use will be covered in depth in the next chapters.
Collapse
Affiliation(s)
- Ruchi R Shah
- Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, USA
| | | | - Luis A Brito
- Moderna Therapeutics, 320 Bent Street, Cambridge, MA, 02139, USA.
| |
Collapse
|
23
|
Song JH, Kim TW, Um YH, Hong SC. Narcolepsy: Association with H1N1 Infection and Vaccination. SLEEP MEDICINE RESEARCH 2016. [DOI: 10.17241/smr.2016.00101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
24
|
Where are we in our understanding of the association between narcolepsy and one of the 2009 adjuvanted influenza A (H1N1) vaccines? Biologicals 2016; 44:276-280. [DOI: 10.1016/j.biologicals.2016.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/19/2016] [Accepted: 04/21/2016] [Indexed: 11/21/2022] Open
|
25
|
Abstract
We previously reported an increased frequency of antibodies to hypocretin (HCRT) receptor 2 in sera obtained from narcoleptic patients who received the European AS03-adjuvanted vaccine Pandemrix (GlaxoSmithKline Biologicals, s.a.) for the global influenza A H1N1 pandemic in 2009 [A(H1N1)pdm09]. These antibodies cross-reacted with a particular fragment of influenza nucleoprotein (NP) - one of the proteins naturally contained in the virus used to make seasonal influenza vaccine and pandemic influenza vaccines. The purpose of this commentary is to provide additional insights and interpretations of the findings and share additional data not presented in the original paper to help the reader appreciate the key messages of that publication. First, a brief background to narcolepsy and vaccine-induced narcolepsy will be provided. Then, additional insights and clarification will be provided on the following topics: 1) the critical difference identified in the adjuvanted A(H1N1)pdm09 vaccines, 2) the contributing factor likely for the discordant association of narcolepsy between the AS03-adjuvanted pandemic vaccines Pandemrix and Arepanrix (GlaxoSmithKline Biologicals, s.a.), 3) the significance of detecting HCRT receptor 2 (HCRTr2) antibodies in some Finnish control subjects, 4) the approach used for the detection of HCRTr2 antibodies in vaccine-associated narcolepsy, and 5) the plausibility of the proposed mechanism involving HCRTr2 modulation in vaccine-associated narcolepsy.
Collapse
Affiliation(s)
| | - Lawrence Steinman
- b Neurology and Neuroscience , Stanford University School of Medicine , Stanford , CA , USA
| |
Collapse
|
26
|
Ahmed SS, Volkmuth W, Duca J, Corti L, Pallaoro M, Pezzicoli A, Karle A, Rigat F, Rappuoli R, Narasimhan V, Julkunen I, Vuorela A, Vaarala O, Nohynek H, Pasini FL, Montomoli E, Trombetta C, Adams CM, Rothbard J, Steinman L. Antibodies to influenza nucleoprotein cross-react with human hypocretin receptor 2. Sci Transl Med 2016; 7:294ra105. [PMID: 26136476 DOI: 10.1126/scitranslmed.aab2354] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The sleep disorder narcolepsy is linked to the HLA-DQB1*0602 haplotype and dysregulation of the hypocretin ligand-hypocretin receptor pathway. Narcolepsy was associated with Pandemrix vaccination (an adjuvanted, influenza pandemic vaccine) and also with infection by influenza virus during the 2009 A(H1N1) influenza pandemic. In contrast, very few cases were reported after Focetria vaccination (a differently manufactured adjuvanted influenza pandemic vaccine). We hypothesized that differences between these vaccines (which are derived from inactivated influenza viral proteins) explain the association of narcolepsy with Pandemrix-vaccinated subjects. A mimic peptide was identified from a surface-exposed region of influenza nucleoprotein A that shared protein residues in common with a fragment of the first extracellular domain of hypocretin receptor 2. A significant proportion of sera from HLA-DQB1*0602 haplotype-positive narcoleptic Finnish patients with a history of Pandemrix vaccination (vaccine-associated narcolepsy) contained antibodies to hypocretin receptor 2 compared to sera from nonnarcoleptic individuals with either 2009 A(H1N1) pandemic influenza infection or history of Focetria vaccination. Antibodies from vaccine-associated narcolepsy sera cross-reacted with both influenza nucleoprotein and hypocretin receptor 2, which was demonstrated by competitive binding using 21-mer peptide (containing the identified nucleoprotein mimic) and 55-mer recombinant peptide (first extracellular domain of hypocretin receptor 2) on cell lines expressing human hypocretin receptor 2. Mass spectrometry indicated that relative to Pandemrix, Focetria contained 72.7% less influenza nucleoprotein. In accord, no durable antibody responses to nucleoprotein were detected in sera from Focetria-vaccinated nonnarcoleptic subjects. Thus, differences in vaccine nucleoprotein content and respective immune response may explain the narcolepsy association with Pandemrix.
Collapse
Affiliation(s)
- Syed Sohail Ahmed
- Global Clinical Sciences, Novartis Vaccines Srl, Siena 53100, Italy.
| | - Wayne Volkmuth
- Informatics and Information Technology, Atreca Inc., Redwood City, CA 94063, USA
| | - José Duca
- Computer-Aided Drug Discovery, Novartis Institutes for BioMedical Research, Cambridge, MA 02139, USA
| | - Lorenzo Corti
- Formulation Analytics, Novartis Vaccines Srl, Siena 53100, Italy
| | - Michele Pallaoro
- Formulation Analytics, Novartis Vaccines Srl, Siena 53100, Italy
| | | | - Anette Karle
- Integrated Biologics Profiling Unit, Novartis Pharma AG, Basel 4057, Switzerland
| | - Fabio Rigat
- Quantitative Sciences, Novartis Vaccines Srl, Siena 53100, Italy
| | | | - Vas Narasimhan
- Development, Novartis Vaccines, Cambridge, MA 02139, USA
| | - Ilkka Julkunen
- National Institute for Health and Welfare (THL), Helsinki 00300, Finland. Virology, University of Turku, Turku 20520, Finland
| | - Arja Vuorela
- National Institute for Health and Welfare (THL), Helsinki 00300, Finland
| | - Outi Vaarala
- National Institute for Health and Welfare (THL), Helsinki 00300, Finland
| | - Hanna Nohynek
- National Institute for Health and Welfare (THL), Helsinki 00300, Finland
| | - Franco Laghi Pasini
- Internal Medicine, Policlinico Santa Maria alle Scotte, Azienda Ospedaliera Universitaria Senese, Siena 53100, Italy. Medical Science, Surgery, and Neuroscience, University of Siena, Siena 53100, Italy
| | - Emanuele Montomoli
- Molecular and Developmental Medicine, University of Siena, Siena 53100, Italy. VisMederi Srl, Siena 53100, Italy
| | - Claudia Trombetta
- Molecular and Developmental Medicine, University of Siena, Siena 53100, Italy
| | - Christopher M Adams
- Stanford University Mass Spectrometry, Stanford University School of Medicine, Palo Alto, CA 94305 USA
| | - Jonathan Rothbard
- Immunology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Lawrence Steinman
- Neurology and Neuroscience, Stanford University School of Medicine, Stanford, CA 94305, USA.
| |
Collapse
|
27
|
Black SW, Yamanaka A, Kilduff TS. Challenges in the development of therapeutics for narcolepsy. Prog Neurobiol 2015; 152:89-113. [PMID: 26721620 DOI: 10.1016/j.pneurobio.2015.12.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 11/14/2015] [Accepted: 12/04/2015] [Indexed: 01/19/2023]
Abstract
Narcolepsy is a neurological disorder that afflicts 1 in 2000 individuals and is characterized by excessive daytime sleepiness and cataplexy-a sudden loss of muscle tone triggered by positive emotions. Features of narcolepsy include dysregulation of arousal state boundaries as well as autonomic and metabolic disturbances. Disruption of neurotransmission through the hypocretin/orexin (Hcrt) system, usually by degeneration of the HCRT-producing neurons in the posterior hypothalamus, results in narcolepsy. The cause of Hcrt neurodegeneration is unknown but thought to be related to autoimmune processes. Current treatments for narcolepsy are symptomatic, including wake-promoting therapeutics that increase presynaptic dopamine release and anticataplectic agents that activate monoaminergic neurotransmission. Sodium oxybate is the only medication approved by the US Food and Drug Administration that alleviates both sleep/wake disturbances and cataplexy. Development of therapeutics for narcolepsy has been challenged by historical misunderstanding of the disease, its many disparate symptoms and, until recently, its unknown etiology. Animal models have been essential to elucidating the neuropathology underlying narcolepsy. These models have also aided understanding the neurobiology of the Hcrt system, mechanisms of cataplexy, and the pharmacology of narcolepsy medications. Transgenic rodent models will be critical in the development of novel therapeutics for the treatment of narcolepsy, particularly efforts directed to overcome challenges in the development of hypocretin replacement therapy.
Collapse
Affiliation(s)
- Sarah Wurts Black
- Center for Neuroscience, Biosciences Division, SRI International, Menlo Park, CA 94025, USA
| | - Akihiro Yamanaka
- Research Institute of Environmental Medicine, Nagoya University, Nagoya 464-8601, Japan
| | - Thomas S Kilduff
- Center for Neuroscience, Biosciences Division, SRI International, Menlo Park, CA 94025, USA.
| |
Collapse
|
28
|
H1N1 influenza virus induces narcolepsy-like sleep disruption and targets sleep-wake regulatory neurons in mice. Proc Natl Acad Sci U S A 2015; 113:E368-77. [PMID: 26668381 DOI: 10.1073/pnas.1521463112] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
An increased incidence in the sleep-disorder narcolepsy has been associated with the 2009-2010 pandemic of H1N1 influenza virus in China and with mass vaccination campaigns against influenza during the pandemic in Finland and Sweden. Pathogenetic mechanisms of narcolepsy have so far mainly focused on autoimmunity. We here tested an alternative working hypothesis involving a direct role of influenza virus infection in the pathogenesis of narcolepsy in susceptible subjects. We show that infection with H1N1 influenza virus in mice that lack B and T cells (Recombinant activating gene 1-deficient mice) can lead to narcoleptic-like sleep-wake fragmentation and sleep structure alterations. Interestingly, the infection targeted brainstem and hypothalamic neurons, including orexin/hypocretin-producing neurons that regulate sleep-wake stability and are affected in narcolepsy. Because changes occurred in the absence of adaptive autoimmune responses, the findings show that brain infections with H1N1 virus have the potential to cause per se narcoleptic-like sleep disruption.
Collapse
|
29
|
Jacob L, Leib R, Ollila HM, Bonvalet M, Adams CM, Mignot E. Comparison of Pandemrix and Arepanrix, two pH1N1 AS03-adjuvanted vaccines differentially associated with narcolepsy development. Brain Behav Immun 2015; 47:44-57. [PMID: 25452148 DOI: 10.1016/j.bbi.2014.11.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/02/2014] [Accepted: 11/06/2014] [Indexed: 01/08/2023] Open
Abstract
Narcolepsy onset in children has been associated with the 2009 influenza A H1N1 pandemic and vaccination with Pandemrix. However it was not clearly observed with other adjuvanted pH1N1 vaccines such as Arepanrix or Focetria. Our aim was to characterize the differences between Pandemrix and Arepanrix that might explain the risk for narcolepsy after Pandemrix vaccination using 2D-DIGE and mass spectrometry (MS). We found that Pandemrix (2009 batch) and Arepanrix (2010 batch) showed 5 main viral proteins: hemagglutinin HA1 and HA2 subunits, neuraminidase NA, nucleoprotein NP, and matrix protein MA1 and non-viral proteins from the Gallus gallus growth matrix used in the manufacturing of the vaccines. Latticed patterns of HA1, HA2 and NA indicated charge and molecular weight heterogeneity, a phenomenon likely caused by glycosylation and sulfation. Overall, Pandemrix contained more NP and NA, while Arepanrix displayed a larger diversity of viral and chicken proteins, with the exception of five chicken proteins (PDCD6IP, TSPAN8, H-FABP, HSP and TUB proteins) that were relatively more abundant in Pandemrix. Glycosylation patterns were similar in both vaccines. A higher degree of deamidation and dioxidation was found in Pandemrix, probably reflecting differential degradation across batches. Interestingly, HA1 146N (residue 129N in the mature protein) displayed a 10-fold higher deamidation in Arepanrix versus Pandemrix. In recent vaccine strains and Focetria, 146N is mutated to D which is associated with increased production yields suggesting that 146N deamidation may have also occurred during the manufacturing of Arepanrix. The presence of 146N in large relative amounts in Pandemrix and the wild type virus and in lower relative quantities in Arepanrix or other H1N1 vaccines may have affected predisposition to narcolepsy.
Collapse
Affiliation(s)
- Louis Jacob
- Center for Sleep Sciences and Medicine, Stanford School of Medicine, Palo Alto, CA, USA
| | - Ryan Leib
- Stanford University Mass Spectrometry, Palo Alto, CA, USA
| | - Hanna M Ollila
- Center for Sleep Sciences and Medicine, Stanford School of Medicine, Palo Alto, CA, USA
| | - Mélodie Bonvalet
- Center for Sleep Sciences and Medicine, Stanford School of Medicine, Palo Alto, CA, USA
| | | | - Emmanuel Mignot
- Center for Sleep Sciences and Medicine, Stanford School of Medicine, Palo Alto, CA, USA.
| |
Collapse
|
30
|
Sturkenboom MCJM. The narcolepsy-pandemic influenza story: Can the truth ever be unraveled? Vaccine 2015; 33 Suppl 2:B6-B13. [DOI: 10.1016/j.vaccine.2015.03.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/05/2015] [Indexed: 11/29/2022]
|
31
|
Bilbo SD, Nevison CD, Parker W. A model for the induction of autism in the ecosystem of the human body: the anatomy of a modern pandemic? MICROBIAL ECOLOGY IN HEALTH AND DISEASE 2015; 26:26253. [PMID: 25634608 PMCID: PMC4310853 DOI: 10.3402/mehd.v26.26253] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023]
Abstract
Background The field of autism research is currently divided based on a fundamental question regarding the nature of autism: Some are convinced that autism is a pandemic of modern culture, with environmental factors at the roots. Others are convinced that the disease is not pandemic in nature, but rather that it has been with humanity for millennia, with its biological and neurological underpinnings just now being understood. Objective In this review, two lines of reasoning are examined which suggest that autism is indeed a pandemic of modern culture. First, given the widely appreciated derailment of immune function by modern culture, evidence that autism is strongly associated with aberrant immune function is examined. Second, evidence is reviewed indicating that autism is associated with ‘triggers’ that are, for the most part, a construct of modern culture. In light of this reasoning, current epidemiological evidence regarding the incidence of autism, including the role of changing awareness and diagnostic criteria, is examined. Finally, the potential role of the microbial flora (the microbiome) in the pathogenesis of autism is discussed, with the view that the microbial flora is a subset of the life associated with the human body, and that the entire human biome, including both the microbial flora and the fauna, has been radically destabilized by modern culture. Conclusions It is suggested that the unequivocal way to resolve the debate regarding the pandemic nature of autism is to perform an experiment: monitor the prevalence of autism after normalizing immune function in a Western population using readily available approaches that address the well-known factors underlying the immune dysfunction in that population.
Collapse
Affiliation(s)
- Staci D Bilbo
- Department of Psychology & Neuroscience, Systems & Integrative Neuroscience Group, Duke University, Durham, NC, USA
| | - Cynthia D Nevison
- Institute for Arctic and Alpine Research, University of Colorado Boulder, Boulder, CO, USA
| | - William Parker
- Department of Surgery, Duke University Medical Center, Durham, NC, USA;
| |
Collapse
|
32
|
Jacob L, Dauvilliers Y. La narcolepsie avec cataplexie : une maladie auto-immune ? Med Sci (Paris) 2014; 30:1136-43. [DOI: 10.1051/medsci/20143012017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
|