1
|
Massa F, Vigo T, Bellucci M, Giunti D, Emanuela MM, Visigalli D, Capodivento G, Cerne D, Assini A, Boni S, Rizzi D, Narciso E, Grisanti GS, Coco E, Uccelli A, Schenone A, Franciotta D, Benedetti L. COVID-19-associated serum and cerebrospinal fluid cytokines in post- versus para-infectious SARS-CoV-2-related Guillain-Barré syndrome. Neurol Sci 2024; 45:849-859. [PMID: 38169013 DOI: 10.1007/s10072-023-07279-6] [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: 11/09/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Guillain-Barré syndrome associated with Coronavirus-2-related severe acute respiratory syndrome (COV-GBS) occurs as para- or post-infectious forms, depending on the timing of disease onset. In these two forms, we aimed to compare the cerebrospinal fluid (CSF) and serum proinflammatory cytokine profiles to evaluate differences that could possibly have co-pathogenic relevance. MATERIALS AND METHODS We studied a retrospective cohort of 26 patients with either post-COV-GBS (n = 15), with disease onset occurring > 7 days after SARS-CoV-2 infection, or para-COV-GBS (n = 11), with disease onset 7 days or less. TNF-α, IL-6, and IL-8 were measured in the serum with SimplePlex™ Ella™ immunoassay. In addition to the para-/post-COV-GBS patients, serum levels of these cytokines were determined in those with non-COVID-associated-GBS (NC-GBS; n = 43), paucisymptomatic SARS-CoV-2 infection without GBS (COVID, n = 20), and in healthy volunteers (HV; n = 12). CSF cytokine levels were measured in patients with para-/post-COV-GBS, in those with NC-GBS (n = 29), or with Alzheimer's disease (AD; n = 24). RESULTS Serum/CSF cytokine levels did not differ in para- vs post-COV-GBS. We found that SARS-CoV-2 infection raises the serum levels of TNF-α, IL-6, and IL-8, as well as an increase of IL-6 (in serum and CSF) and IL-8 (in CSF) in either NC-GBS or COV-GBS than controls. CSF and serum cytokine levels resulted independent one with another. CONCLUSIONS The change of cytokines linked to SARS-CoV-2 in COV-GBS appears to be driven by viral infection, although it has unique characteristics in GBS as such and does not account for cases with para- or post-infectious onset.
Collapse
Affiliation(s)
- Federico Massa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy.
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy.
| | - Tiziana Vigo
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Margherita Bellucci
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
| | - Debora Giunti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | | | - Davide Visigalli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Giovanna Capodivento
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Denise Cerne
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
| | - Andrea Assini
- Neurology Unit, Galliera Hospital, Via Mura Delle Cappuccine 14, 1628, Genova, Italy
| | - Silvia Boni
- Department of Infectious Diseases, Galliera Hospital, Via Mura Delle Cappuccine 14, 1628, Genoa, Italy
| | - Domenica Rizzi
- Neurology Unit, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Eleonora Narciso
- Department of Neurology, ASL3 Genovese, Corso Onofrio Scassi 1, 16149, Genova, Italy
| | - Giuseppe Stefano Grisanti
- Department of Neurology, Santa Corona Hospital, Viale XXV Aprile 38, 17027, Pietra Ligure, Savona, Italy
| | - Elena Coco
- Department of Neurology, Santa Corona Hospital, Viale XXV Aprile 38, 17027, Pietra Ligure, Savona, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | - Angelo Schenone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| | | | - Luana Benedetti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Largo Paolo Daneo 3, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, Italy
| |
Collapse
|
2
|
Costigan D, Fenn J, Yen S, Ilott N, Bullers S, Hale J, Greenhalf W, Conibear E, Koycheva A, Madon K, Jahan I, Huang M, Badhan A, Parker E, Rosadas C, Jones K, McClure M, Tedder R, Taylor G, Baillie KJ, Semple MG, Openshaw PJM, Pearson C, Johnson J, Lalvani A, Thornton EE. A pro-inflammatory gut mucosal cytokine response is associated with mild COVID-19 disease and superior induction of serum antibodies. Mucosal Immunol 2024; 17:111-123. [PMID: 37995912 PMCID: PMC10884467 DOI: 10.1016/j.mucimm.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/25/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023]
Abstract
The relationship between gastrointestinal tract infection, the host immune response, and the clinical outcome of disease is not well understood in COVID-19. We sought to understand the effect of intestinal immune responses to SARS-CoV-2 on patient outcomes including the magnitude of systemic antibody induction. Combining two prospective cohort studies, International Severe Acute Respiratory and emerging Infections Consortium Comprehensive Clinical Characterisations Collaboration (ISARIC4C) and Integrated Network for Surveillance, Trials and Investigations into COVID-19 Transmission (INSTINCT), we acquired samples from 88 COVID-19 cases representing the full spectrum of disease severity and analysed viral RNA and host gut cytokine responses in the context of clinical and virological outcome measures. There was no correlation between the upper respiratory tract and faecal viral loads. Using hierarchical clustering, we identified a group of fecal cytokines including Interleukin-17A, Granulocyte macrophage colony-stimulating factor, Tumor necrosis factorα, Interleukin-23, and S100A8, that were transiently elevated in mild cases and also correlated with the magnitude of systemic anti-Spike-receptor-binding domain antibody induction. Receiver operating characteristic curve analysis showed that expression of these gut cytokines at study enrolment in hospitalised COVID-19 cases was associated negatively with overall clinical severity implicating a protective role in COVID-19. This suggests that a productive intestinal immune response may be beneficial in the response to a respiratory pathogen and a biomarker of a successful barrier response.
Collapse
Affiliation(s)
- Dana Costigan
- MRC Translational Immune Discovery Unit, Weatherall Institute of Molecular Medicine, University of Oxford, UK
| | - Joe Fenn
- NIHR HPRU in Respiratory Infections, Imperial College London, London, UK.
| | - Sandi Yen
- Oxford Centre for Microbiome Studies, Kennedy Institute of Rheumatology, University of Oxford, UK
| | - Nicholas Ilott
- Oxford Centre for Microbiome Studies, Kennedy Institute of Rheumatology, University of Oxford, UK
| | - Samuel Bullers
- Oxford Centre for Microbiome Studies, Kennedy Institute of Rheumatology, University of Oxford, UK; Kennedy Institute of Rheumatology, University of Oxford, UK
| | - Jessica Hale
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - William Greenhalf
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Emily Conibear
- NIHR HPRU in Respiratory Infections, Imperial College London, London, UK
| | | | - Kieran Madon
- NIHR HPRU in Respiratory Infections, Imperial College London, London, UK
| | - Ishrat Jahan
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Ming Huang
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Anjna Badhan
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Eleanor Parker
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Carolina Rosadas
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Kelsey Jones
- Kennedy Institute of Rheumatology, University of Oxford, UK
| | - Myra McClure
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Richard Tedder
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Graham Taylor
- Section of Virology, Department of Infectious Disease, Imperial College London, London, UK
| | - Kenneth J Baillie
- Roslin Institute, University of Edinburgh, Easter Bush, Edinburgh, UK
| | - Malcolm G Semple
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Peter J M Openshaw
- NIHR HPRU in Respiratory Infections, Imperial College London, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Claire Pearson
- Oxford Centre for Microbiome Studies, Kennedy Institute of Rheumatology, University of Oxford, UK; Kennedy Institute of Rheumatology, University of Oxford, UK
| | - Jethro Johnson
- Oxford Centre for Microbiome Studies, Kennedy Institute of Rheumatology, University of Oxford, UK
| | - Ajit Lalvani
- NIHR HPRU in Respiratory Infections, Imperial College London, London, UK
| | - Emily E Thornton
- MRC Translational Immune Discovery Unit, Weatherall Institute of Molecular Medicine, University of Oxford, UK; Nuffield Department of Medicine, University of Oxford, UK.
| |
Collapse
|
3
|
Zhou J, Singanayagam A, Goonawardane N, Moshe M, Sweeney FP, Sukhova K, Killingley B, Kalinova M, Mann AJ, Catchpole AP, Barer MR, Ferguson NM, Chiu C, Barclay WS. Viral emissions into the air and environment after SARS-CoV-2 human challenge: a phase 1, open label, first-in-human study. THE LANCET. MICROBE 2023; 4:e579-e590. [PMID: 37307844 PMCID: PMC10256269 DOI: 10.1016/s2666-5247(23)00101-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Effectively implementing strategies to curb SARS-CoV-2 transmission requires understanding who is contagious and when. Although viral load on upper respiratory swabs has commonly been used to infer contagiousness, measuring viral emissions might be more accurate to indicate the chance of onward transmission and identify likely routes. We aimed to correlate viral emissions, viral load in the upper respiratory tract, and symptoms, longitudinally, in participants who were experimentally infected with SARS-CoV-2. METHODS In this phase 1, open label, first-in-human SARS-CoV-2 experimental infection study at quarantine unit at the Royal Free London NHS Foundation Trust, London, UK, healthy adults aged 18-30 years who were unvaccinated for SARS-CoV-2, not previously known to have been infected with SARS-CoV-2, and seronegative at screening were recruited. Participants were inoculated with 10 50% tissue culture infectious dose of pre-alpha wild-type SARS-CoV-2 (Asp614Gly) by intranasal drops and remained in individual negative pressure rooms for a minimum of 14 days. Nose and throat swabs were collected daily. Emissions were collected daily from the air (using a Coriolis μ air sampler and directly into facemasks) and the surrounding environment (via surface and hand swabs). All samples were collected by researchers, and tested by using PCR, plaque assay, or lateral flow antigen test. Symptom scores were collected using self-reported symptom diaries three times daily. The study is registered with ClinicalTrials.gov, NCT04865237. FINDINGS Between March 6 and July 8, 2021, 36 participants (ten female and 26 male) were recruited and 18 (53%) of 34 participants became infected, resulting in protracted high viral loads in the nose and throat following a short incubation period, with mild-to-moderate symptoms. Two participants were excluded from the per-protocol analysis owing to seroconversion between screening and inoculation, identified post hoc. Viral RNA was detected in 63 (25%) of 252 Coriolis air samples from 16 participants, 109 (43%) of 252 mask samples from 17 participants, 67 (27%) of 252 hand swabs from 16 participants, and 371 (29%) of 1260 surface swabs from 18 participants. Viable SARS-CoV-2 was collected from breath captured in 16 masks and from 13 surfaces, including four small frequently touched surfaces and nine larger surfaces where airborne virus could deposit. Viral emissions correlated more strongly with viral load in nasal swabs than throat swabs. Two individuals emitted 86% of airborne virus, and the majority of airborne virus collected was released on 3 days. Individuals who reported the highest total symptom scores were not those who emitted most virus. Very few emissions occurred before the first reported symptom (7%) and hardly any before the first positive lateral flow antigen test (2%). INTERPRETATION After controlled experimental inoculation, the timing, extent, and routes of viral emissions was heterogeneous. We observed that a minority of participants were high airborne virus emitters, giving support to the notion of superspreading individuals or events. Our data implicates the nose as the most important source of emissions. Frequent self-testing coupled with isolation upon awareness of first symptoms could reduce onward transmissions. FUNDING UK Vaccine Taskforce of the Department for Business, Energy and Industrial Strategy of Her Majesty's Government.
Collapse
Affiliation(s)
- Jie Zhou
- Section of Virology, Imperial College London, London, UK
| | - Anika Singanayagam
- Section of Adult Infectious Disease, Imperial College London, London, UK
| | | | - Maya Moshe
- Section of Virology, Imperial College London, London, UK
| | | | - Ksenia Sukhova
- Section of Virology, Imperial College London, London, UK
| | - Ben Killingley
- Department of Infectious Diseases, University College London Hospital, London, UK
| | | | | | | | - Michael R Barer
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Neil M Ferguson
- Department of Infectious Disease, and MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Christopher Chiu
- Section of Adult Infectious Disease, Imperial College London, London, UK
| | | |
Collapse
|
4
|
Lee GH, Park SH, Song BM, Kim DM, Han HJ, Park JY, Jo YW, Hwang MY, Sim KT, Kang SM, Tark D. Comparative efficacy evaluation of disinfectants against severe acute respiratory syndrome coronavirus-2. J Hosp Infect 2023; 131:12-22. [PMID: 36183929 PMCID: PMC9639569 DOI: 10.1016/j.jhin.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Disinfection is one of the most effective ways to block the rapid transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Due to the prolonged coronavirus disease 2019 (COVID-19) pandemic, disinfectants have become crucial to prevent person-to-person transmission and decontaminate hands, clothes, facilities and equipment. However, there is a lack of accurate information on the virucidal activity of commercial disinfectants. AIM To evaluate the virucidal efficacy of 72 commercially available disinfectants constituting 16 types of ingredients against SARS-CoV-2. METHODS SARS-CoV-2 was tested with various concentrations of disinfectants at indicated exposure time points as recommended by the manufacturers. The 50% tissue culture infectious dose assay was used to calculate virus titre, and trypan blue staining and CCK-8 were used to assess cell viability after 3-5 days of SARS-CoV-2 infection. FINDINGS This study found that disinfectants based on 83% ethanol, 60% propanol/ethanol, 0.00108-0.0011% sodium dichloroisocyanurate and 0.497% potassium peroxymonosulfate inactivated SARS-CoV-2 effectively and safely. Although disinfectants based on 0.05-0.4% benzalkonium chloride (BAC), 0.02-0.07% quaternary ammonium compound (QAC; 1:1), 0.4% BAC/didecyldimethylammonium chloride (DDAC), 0.28% benzethonium chloride concentrate/2-propanol, 0.0205-0.14% DDAC/polyhexamethylene biguanide hydrochloride (PHMB) and 0.5% hydrogen peroxide inactivated SARS-CoV-2 effectively, they exhibited cytotoxicity. Conversely, disinfectants based on 0.04-4% QAC (2:3), 0.00625% BAC/DDAC/PHMB, and 0.0205-0.14% and 0.0173% peracetic acid showed approximately 50% virucidal efficacy with no cytotoxicity. Citric acid (0.4%) did not inactivate SARS-CoV-2. CONCLUSION These results indicate that most commercially available disinfectants exert a disinfectant effect against SARS-CoV-2. However, re-evaluation of the effective concentration and exposure time of certain disinfectants is needed, especially citric acid and peracetic acid.
Collapse
Affiliation(s)
- G-H. Lee
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea
| | - S-H. Park
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea
| | - B-M. Song
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea
| | - D-M. Kim
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea
| | - H-J. Han
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea
| | - J-Y. Park
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea
| | - Y-W. Jo
- Division of Chemical Research, National Institute of Environmental Research, Incheon, Republic of Korea
| | - M-Y. Hwang
- Division of Chemical Research, National Institute of Environmental Research, Incheon, Republic of Korea
| | - K-T. Sim
- Division of Chemical Research, National Institute of Environmental Research, Incheon, Republic of Korea
| | - S-M. Kang
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea,Corresponding author. Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan 54531, Republic of Korea
| | - D. Tark
- Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan, Republic of Korea,Corresponding author. Laboratory for Infectious Disease Prevention, Korea Zoonosis Research Institute, Jeonbuk National University, Iksan 54531, Republic of Korea
| |
Collapse
|
5
|
Deeks JJ, Singanayagam A, Houston H, Sitch AJ, Hakki S, Dunning J, Lalvani A. SARS-CoV-2 antigen lateral flow tests for detecting infectious people: linked data analysis. BMJ 2022; 376:e066871. [PMID: 35197270 PMCID: PMC8864475 DOI: 10.1136/bmj-2021-066871] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To investigate the proportion of lateral flow tests (LFTs) that produce negative results in those with a high risk of infectiousness from SARS-CoV-2, to investigate the impact of the stage and severity of disease, and to compare predictions made by influential mathematical models with findings of empirical studies. DESIGN Linked data analysis combining empirical evidence of the accuracy of the Innova LFT, the probability of positive viral culture or transmission to secondary cases, and the distribution of viral loads of SARS-CoV-2 in individuals in different settings. SETTING Testing of individuals with symptoms attending NHS Test-and-Trace centres across the UK, residents without symptoms attending municipal mass testing centres in Liverpool, and students without symptoms screened at the University of Birmingham. PARTICIPANTS Evidence for the sensitivity of the Innova LFT, based on 70 individuals with SARS-CoV-2 and LFT results. Infectiousness was based on viral culture rates on 246 samples (176 people with SARS-CoV-2) and secondary cases among 2 474 066 contacts; distributions of cycle threshold (Ct) values from 231 497 index individuals attending NHS Test-and-Trace centres; 70 people with SARS-CoV-2 detected in Liverpool and 62 people with SARS-CoV-2 in Birmingham (54 imputed). MAIN OUTCOME MEASURES The predicted proportions who were missed by LFT and viral culture positive and missed by LFT and sources of secondary cases, in each of the three settings. Predictions were compared with those made by mathematical models. RESULTS The analysis predicted that of those with a viral culture positive result, Innova would miss 20% attending an NHS Test-and-Trace centre, 29% without symptoms attending municipal mass testing, and 81% attending university screen testing without symptoms, along with 38%, 47%, and 90% of sources of secondary cases. In comparison, two mathematical models underestimated the numbers of missed infectious individuals (8%, 10%, and 32% in the three settings for one model, whereas the assumptions from the second model made it impossible to miss an infectious individual). Owing to the paucity of usable data, the inputs to the analyses are from limited sources. CONCLUSIONS The proportion of infectious people with SARS-CoV-2 missed by LFTs is substantial enough to be of clinical importance. The proportion missed varied between settings because of different viral load distributions and is likely to be highest in those without symptoms. Key models have substantially overestimated the sensitivity of LFTs compared with empirical data. An urgent need exists for additional robust well designed and reported empirical studies from intended use settings to inform evidence based policy.
Collapse
Affiliation(s)
- Jonathan J Deeks
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, UK and University of Birmingham, UK
| | - Anika Singanayagam
- NIHR Health Protection Research Unit in Respiratory Infections, National Heart and Lung Institute, Imperial College London, London, UK
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Hamish Houston
- NIHR Health Protection Research Unit in Respiratory Infections, National Heart and Lung Institute, Imperial College London, London, UK
| | - Alice J Sitch
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, UK and University of Birmingham, UK
| | - Seran Hakki
- NIHR Health Protection Research Unit in Respiratory Infections, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jake Dunning
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Ajit Lalvani
- NIHR Health Protection Research Unit in Respiratory Infections, National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|