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Snyder RE, Saadeh K, Tang EC, Johnson KA, Holland SN, Quint J, Burghardt NO, Chai SJ, Fernando R, Barrera KG, Hernandez C, McManus K, Lorenz K, Maycott J, McGinley J, Lewnard JA. Sexual Exposures Associated With Mpox Infection: California, November 2022 to June 2023. J Infect Dis 2024; 229:S188-S196. [PMID: 37820738 DOI: 10.1093/infdis/jiad447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/02/2023] [Accepted: 10/09/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Exposures associated with mpox infection remain imperfectly understood. METHODS We conducted a case-control study enrolling participants who received molecular tests for mpox/orthopoxvirus in California from November 2022 through June 2023. We collected data on behaviors during a 21-day risk period before symptom onset or testing among mpox case patients and test-negative controls. RESULTS Thirteen of 54 case patients (24.1%) and 5 of 117 controls (4.3%) reported sexual exposure to individuals they identified as potential mpox case patients ("index contacts"; odds ratio [OR], 7.7 [95% confidence interval (CI), 2.5-19.3] relative to individuals who did not report exposure to potential mpox case patients). Among these participants, 10 of 13 case patients (76.9%) and 2 of 5 controls (40.0%) reported that their index contacts were not experiencing symptoms visible to participants during sex (OR, 14.9 [95% CI, 3.6-101.8]). Only 3 of 54 case patients (5.6%) reported exposure to symptomatic index contacts. Case patients reported more anal/vaginal sex partners than did controls (adjusted OR, 2.2 [95% CI, 1.0-4.8] for 2-3 partners and 3.8 [1.7-8.8] for ≥4 partners). Male case patients with penile lesions more commonly reported insertive anal/vaginal sex than those without penile lesions (adjusted OR, 9.3 [95% CI, 1.6-54.8]). Case patients with anorectal lesions more commonly reported receptive anal sex than those without anorectal lesions (adjusted OR, 14.4 [95% CI, 1.0-207.3]). CONCLUSIONS Sexual exposure to contacts known or suspected to have experienced mpox was associated with increased risk of infection, often when index contacts lacked apparent symptoms. Exposure to more sex partners, including those whom participants did not identify as index contacts, was associated with increased risk of infection in a site-specific manner. While participants' assessment of symptoms in partners may be imperfect, these findings suggest that individuals without visibly prominent mpox symptoms transmit infection.
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Affiliation(s)
- Robert E Snyder
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Kayla Saadeh
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Eric C Tang
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Kelly A Johnson
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Samuel N Holland
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
- School of Public Health, University of California, Berkeley, California, USA
| | - Joshua Quint
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Nicole O Burghardt
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Shua J Chai
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
- Career Epidemiology Field Officer Program, Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Roshani Fernando
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Kimberly Gonzalez Barrera
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Cindy Hernandez
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
| | - Korie McManus
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
- School of Public Health, University of California, Berkeley, California, USA
| | - Kieran Lorenz
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
- School of Public Health, University of California, Berkeley, California, USA
| | - Jarett Maycott
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
- School of Public Health, University of California, Berkeley, California, USA
| | - John McGinley
- Sexually Transmitted Diseases Control Branch, California Department of Public Health, Richmond and Sacramento, California, USA
- School of Public Health, University of California, Berkeley, California, USA
| | - Joseph A Lewnard
- School of Public Health, University of California, Berkeley, California, USA
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Zhang Z, Jiang H, Jiang S, Dong T, Wang X, Wang Y, Li Y. Rapid Detection of the Monkeypox Virus Genome and Antigen Proteins Based on Surface-Enhanced Raman Spectroscopy. ACS APPLIED MATERIALS & INTERFACES 2023; 15:34419-34426. [PMID: 37436060 DOI: 10.1021/acsami.3c04285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
The conventional detection methods cannot satisfy the need for early and rapid detection of monkeypox virus (MPXV) infection. This is due to complicated pretreatment, time consumption, and complex operation of the diagnostic tests. Based on surface-enhanced Raman spectroscopy (SERS), this study attempted to capture the characteristic fingerprints of the MPXV genome and multiple antigenic proteins without the need to design specific probes. The minimum detection limit of this method is 100 copies/mL, with good reproducibility and signal-to-noise ratio. Therefore, the relationship between characteristic peak intensity and the protein and nucleic acid concentration can be used to construct a concentration-dependent spectral line with a good linear relationship. Additionally, principal component analysis (PCA) could identify the SERS spectra of four different MPXV proteins in serum. Therefore, this rapid detection method in the current outbreak of monkeypox control and the future response to possible new outbreaks has broad application prospects.
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Affiliation(s)
- Zhe Zhang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), College of Pharmacy, Harbin Medical University, Baojian Road No. 157, Harbin 150081, Heilongjiang, China
| | - Heng Jiang
- College of Public Health, Harbin Medical University, Baojian Road No. 157, Harbin 150081, Heilongjiang, China
| | - Shen Jiang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), College of Pharmacy, Harbin Medical University, Baojian Road No. 157, Harbin 150081, Heilongjiang, China
| | - Tuo Dong
- College of Public Health, Harbin Medical University, Baojian Road No. 157, Harbin 150081, Heilongjiang, China
| | - Xiaotong Wang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), College of Pharmacy, Harbin Medical University, Baojian Road No. 157, Harbin 150081, Heilongjiang, China
| | - Yunpeng Wang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), College of Pharmacy, Harbin Medical University, Baojian Road No. 157, Harbin 150081, Heilongjiang, China
| | - Yang Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), College of Pharmacy, Harbin Medical University, Baojian Road No. 157, Harbin 150081, Heilongjiang, China
- Research Unit of Health Sciences and Technology (HST), Faculty of Medicine, University of Oulu, Oulu 90220, Finland
- Genomics Research Center (Key Laboratory of Gut Microbiota and Pharmacogenomics of Heilongjiang Province), College of Pharmacy, Harbin Medical University, Harbin 150081, China
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McFarland SE, Marcus U, Hemmers L, Miura F, Iñigo Martínez J, Martínez FM, Montalbán EG, Chazelle E, Mailles A, Silue Y, Hammami N, Lecompte A, Ledent N, Vanden Berghe W, Liesenborghs L, Van den Bossche D, Cleary PR, Wallinga J, Robinson EP, Johansen TB, Bormane A, Melillo T, Seidl C, Coyer L, Boberg R, Jurke A, Werber D, Bartel A. Estimated incubation period distributions of mpox using cases from two international European festivals and outbreaks in a club in Berlin, May to June 2022. Euro Surveill 2023; 28:2200806. [PMID: 37410383 PMCID: PMC10370040 DOI: 10.2807/1560-7917.es.2023.28.27.2200806] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/13/2023] [Indexed: 07/07/2023] Open
Abstract
BackgroundSince May 2022, an mpox outbreak affecting primarily men who have sex with men (MSM) has occurred in numerous non-endemic countries worldwide. As MSM frequently reported multiple sexual encounters in this outbreak, reliably determining the time of infection is difficult; consequently, estimation of the incubation period is challenging.AimWe aimed to provide valid and precise estimates of the incubation period distribution of mpox by using cases associated with early outbreak settings where infection likely occurred.MethodsColleagues in European countries were invited to provide information on exposure intervals and date of symptom onset for mpox cases who attended a fetish festival in Antwerp, Belgium, a gay pride festival in Gran Canaria, Spain or a particular club in Berlin, Germany, where early mpox outbreaks occurred. Cases of these outbreaks were pooled; doubly censored models using the log-normal, Weibull and Gamma distributions were fitted to estimate the incubation period distribution.ResultsWe included data on 122 laboratory-confirmed cases from 10 European countries. Depending on the distribution used, the median incubation period ranged between 8 and 9 days, with 5th and 95th percentiles ranging from 2 to 3 and from 20 to 23 days, respectively. The shortest interval that included 50% of incubation periods spanned 8 days (4-11 days).ConclusionCurrent public health management of close contacts should consider that in approximately 5% of cases, the incubation period exceeds the commonly used monitoring period of 21 days.
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Affiliation(s)
- Sarah E McFarland
- Unit for Surveillance and Epidemiology of Infectious Diseases, State Office for Health and Social Affairs (SOHSA), Berlin, Germany
| | - Ulrich Marcus
- Unit 'HIV/AIDS, STI and Blood-borne Infections', Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Lukas Hemmers
- Unit for Surveillance and Epidemiology of Infectious Diseases, State Office for Health and Social Affairs (SOHSA), Berlin, Germany
- Postgraduate Training for Applied Epidemiology (PAE), Robert Koch Institute, Berlin, Germany
- ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Fuminari Miura
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Center for Marine Environmental Studies (CMES), Ehime University, Ehime, Japan
| | - Jesús Iñigo Martínez
- Directorate General of Public Health, Regional Ministry of Health of Madrid, Madrid, Spain
| | | | - Elisa Gil Montalbán
- Directorate General of Public Health, Regional Ministry of Health of Madrid, Madrid, Spain
| | - Emilie Chazelle
- Santé publique France, the French national public health agency, Saint-Maurice, France
| | - Alexandra Mailles
- Santé publique France, the French national public health agency, Saint-Maurice, France
| | - Yassoungo Silue
- Santé publique France, the French national public health agency, Paris area regional office, Saint-Denis, France
| | - Naïma Hammami
- Department of Infectious Disease Prevention and Control, Agency for Care and Health, Flemish Region, Brussels, Belgium
| | - Amaryl Lecompte
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Nicolas Ledent
- Department of Infectious Disease Prevention and Control, Common Community Commission, Brussels-Capital Region, Brussels, Belgium
| | - Wim Vanden Berghe
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Laurens Liesenborghs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Paul R Cleary
- Field Service North West, UK Health Security Agency, Liverpool, United Kingdom
| | - Jacco Wallinga
- Department of Biomedical Data Sciences, Leiden University Medical Center (LUMC), Leiden, the Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | | | - Tone Bjordal Johansen
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Antra Bormane
- Diseases Surveillance and Immunization Unit, Centre for Disease Prevention and Control, Riga, Latvia
| | - Tanya Melillo
- Infectious Disease Prevention and Control Unit, HPDP, Department for Health Regulation, Ministry of Health, Gwardamangia, Malta
| | - Cornelia Seidl
- Bavarian Health and Food Safety Authority (LGL), Munich, Germany
- Postgraduate Training for Applied Epidemiology (PAE), Robert Koch Institute, Berlin, Germany
- ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Liza Coyer
- Bavarian Health and Food Safety Authority (LGL), Munich, Germany
- ECDC Fellowship Programme, Field Epidemiology path (EPIET), European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Ronja Boberg
- State Office for Occupational Safety, Consumer Protection and Health, Brandenburg, Germany
| | - Annette Jurke
- NRW Centre for Health, North Rhine-Westphalia, Bochum, Germany
| | - Dirk Werber
- Unit for Surveillance and Epidemiology of Infectious Diseases, State Office for Health and Social Affairs (SOHSA), Berlin, Germany
| | - Alexander Bartel
- Unit for Surveillance and Epidemiology of Infectious Diseases, State Office for Health and Social Affairs (SOHSA), Berlin, Germany
- Freie Universität Berlin, Berlin, Germany
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Brosius I, Dijck CV, Coppens J, Vandenhove L, Bangwen E, Vanroye F, Verschueren J, Zange S, Bugert J, Michiels J, Bottieau E, Soentjens P, van Griensven J, Kenyon C, Ariën KK, Esbroeck MV, Vercauteren K, Liesenborghs L. Presymptomatic viral shedding in high-risk mpox contacts: A prospective cohort study. J Med Virol 2023; 95:e28769. [PMID: 37212312 DOI: 10.1002/jmv.28769] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/08/2023] [Indexed: 05/23/2023]
Abstract
The risk of infection after exposure to clade IIb mpox virus (MPXV) is unknown, and potential presymptomatic shedding of MPXV remains to be demonstrated. High-risk contacts of mpox patients were followed-up in a prospective longitudinal cohort study. Individuals reporting sexual contact, >15 min skin-to-skin contact, or living in the same household with an mpox patient were recruited in a sexual health clinic in Antwerp, Belgium. Participants kept a symptom diary, performed daily self-sampling (anorectal, genital, and saliva), and presented for weekly clinic visits for physical examination and sampling (blood and oropharyngeal). Samples were tested for MPXV by PCR. Between June 24 and July 31, 2022, 25 contacts were included, of which 12/18 (66.0%) sexual and 1/7 (14.0%) nonsexual contacts showed evidence of infection by MPXV-PCR. Six cases had typical mpox symptoms. Viral DNA was detected as early as 4 days before symptom onset in 5 of them. In 3 of these cases, replication-competent virus was demonstrated in the presymptomatic phase. These findings confirm the existence of presymptomatic shedding of replication-competent MPXV and emphasize the high risk of transmission during sexual contact. Sexual contacts of mpox cases should abstain from sex during the incubation period, irrespective of symptoms.
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Affiliation(s)
- Isabel Brosius
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Christophe Van Dijck
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Jasmine Coppens
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Leen Vandenhove
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Eugene Bangwen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Fien Vanroye
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jacob Verschueren
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sabine Zange
- Bundeswehr Institute of Microbiology, Munich, Germany
| | | | - Johan Michiels
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Patrick Soentjens
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Johan van Griensven
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Chris Kenyon
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin K Ariën
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Marjan Van Esbroeck
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Koen Vercauteren
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Laurens Liesenborghs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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5
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Prasad S, Galvan Casas C, Strahan AG, Fuller LC, Peebles K, Carugno A, Leslie KS, Harp JL, Pumnea T, McMahon DE, Rosenbach M, Lubov JE, Chen G, Fox LP, McMillen A, Lim HW, Stratigos AJ, Cronin TA, Kaufmann MD, Hruza GJ, French LE, Freeman EE. A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: Skin lesion morphology, clinical course, and scarring. J Am Acad Dermatol 2023; 88:1066-1073. [PMID: 36641010 PMCID: PMC9833815 DOI: 10.1016/j.jaad.2022.12.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/12/2022] [Accepted: 12/17/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression. OBJECTIVE The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time. METHODS The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals. RESULTS From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5 days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases. LIMITATIONS Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity. DISCUSSION These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela.
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Affiliation(s)
- Sonya Prasad
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Cristina Galvan Casas
- Department of Dermatology, University Hospital Mostoles, Madrid, Spain; Fundación Lluita contra les Infeccions, Hospital Germans Trias i Puyol, Badalona, Barcelona, Spain
| | - Alexis G Strahan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Mercer University School of Medicine, Savannah, Georgia
| | - L Claire Fuller
- Chelsea and Westminster NHS Foundation Trust, London, UK; International Foundation for Dermatology, London, UK
| | - Klint Peebles
- Department of Dermatology, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland
| | - Andrea Carugno
- Dermatology Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy; Ph.D. Program in Molecular and Translational Medicine (DIMET), University of Milan-Bicocca, Milan, Italy
| | - Kieron S Leslie
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | - Joanna L Harp
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Teodora Pumnea
- Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany
| | - Devon E McMahon
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Janet E Lubov
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Geoffrey Chen
- Medical Practice Evaluation Foundation, Massachusetts General Hospital, Boston, Massachusetts
| | - Lindy P Fox
- Department of Dermatology, University of California San Francisco, San Francisco, California
| | | | - Henry W Lim
- Department of Dermatology, Henry Ford Health, Detroit, Michigan
| | - Alexander J Stratigos
- First Department of Dermatology-Venereology, National and Kapodistrian University of Athens, Andreas Sygros Hospital, Athens, Greece
| | - Terrence A Cronin
- Department of Dermatology and Cutaneous Surgery, University of Miami, Melbourne, Florida
| | - Mark D Kaufmann
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George J Hruza
- Department of Dermatology, Saint Louis University, Saint Louis, Missouri
| | - Lars E French
- Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany; Dr Philip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Foundation, Massachusetts General Hospital, Boston, Massachusetts.
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